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HX641 22794 
RC311  .As7  Tuberculosis  familie 


RECAP 


Tuberculosis  Familie.  .a 
Their  Homes 


A  Study 


The  ^Association  of  Tuberculosis J3inics  4. 

and  the 

Committee  on  the  Prevention  of  Tuberculosis 

of  the  I 

Charity  Organization  Society 

New  York  City 

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Columbia  (inttierssftp 
tntJ)eCttpofl^rtt»gork 

CoUege  of  ^})|>siictansi  anli  burgeons; 

Hihvarp 


Digitized  by  tine  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/tuberculosisfamiOOnewy 


Tuberculosis  Families  in 
Their  Homes 


A  Study 


The  Association  of  Tuberculosis  Clinics 

and  the 

Committee  on  the  Prevention  of  Tuberculosis 

of  the 

Charity  Organization  Society 

New  York  City 

iqi6 


0^1 


Foreword 

THE  present  study  was  begun  in  19 13,  and  continued  inter- 
mittently over  a  period  of  two  years.  The  length  of  time 
required  for  its  completion  and  its  final  presentation  has 
been  due  to  two  causes :  first,  that  the  study  was  carried  on  sim- 
ultaneously with  the  regular  routine  work  of  the  Executive  Office 
of  the  Association,  so  that  it  was  not  possible  to  give  full  and 
undivided  attention  to  it ;  second,  to  the  unavoidable  delay  result- 
ing from  the  necessity  of  submitting  it  for  final  approval  to  the 
various  workers  more  or  less  directly  interested  in  it,  either 
through  its  conduct  or  because  of  their  association  with  the  agen- 
cies caring  for  the  families  included  in  the  study. 

It  is  unfortunate  that  the  general  impression  left  by  the  study 
as  a  whole  is  more  or  less  pessimistic.  Part  II  of  the  report  deals 
with  avowedly  "difficult  families"  more  or  less  unhelpable  from 
the  outset.  Success  could  hardly  be  expected  to  follow  in  the 
wake  of  the  most  expert  social  and  medical  care,  all  things  con- 
sidered. It  is  only  fair  to  remind  the  reader  that  successful  re- 
sults zvere  obtained  by  social  and  medical  agencies  with  other 
helpahle  families  under  their  care  during  the  same  period  of  time. 

Unquestionably  the  technique  of  both  medical  and  social 
workers  is  improving  from  year  to  year,  but  the  problem  of  the 
apparently  unhelpable  family  still  remains  unsolved.  Whether 
private  agencies  will  ever  be  able  to  handle  these  families  effec- 
tively, or  whether  their  care  should  be  put  directly  up  to  the  pub- 
lic authorities,  is  a  question  that  should  receive  more  careful  con- 
sideration than  it  has  in  the  past. 

The  report  has  been  criticised  as  lacking  in  constructive  sug- 
gestions for  the  care  of  tuberculosis  families  generally.  It  should 
be  noted  that  the  study  was  undertaken  primarily  to  let  a  little 
light,  if  possible,  into  dark  places  which  are  being  encountered  by 
auxiliary  organizations  to  the  tuberculosis  clinics  of  New  York 
City,  and  to  bring  home  to  them  the  futility  of  their  attempting  to 


handle  these  "difficult"  families  with  the  hmited  facilities  for  in- 
tensive social  work  at  their  command.  It  also  attempted  to  point 
out  to  them  what  might  be  considered  a  reasonable  expenditure  of 
the  not  inconsiderable  funds  which  they  raise  for  tuberculosis 
work. 

Because  of  the  possibly  discouraging  effect  the  report  might 
have  on  those  whose  background  is  insufficient  to  enable  them  to 
properly  interpret  the  reasons  for  the  apparent  failure  in  dealing 
with  the  families  included  in  this  study,  it  has  seemed  wise  to 
limit  its  distribution  to  professional  workers.  It  is  offered  to 
them  with  the  sincere  hope  that  it  may  prove  of  some  slight  help 
in  meeting  those  difficult  problems  arising  out  of  a  combination 
of  chronic  disabling  disease  and  inherent  lack  of  capacity. 

As  to  the  omission  of  broader  constructive  recommendations 
regarding  the  care  of  dependent  tuberculous  families  by  social 
agencies  possessing  all  the  necessary  equipment  for  adequate  fol- 
low-up work,  it  would  seem  that  their  policy  must  be  determined 
largely  by  the  attitude  of  the  health  authorities  as  to  the  degree 
of  control  they  are  willing  to  exercise  over  the  avowedly  danger- 
ous foci  of  infection,  the  active  cases  living  under  improper  home 
conditions.  The  final  responsibility  here  undoubtedly  rests  with 
the  medical  profession.  Until  they  are  willing  to  sanction  the 
wholesale  segregation  of  dangerous  tuberculosis  carriers,  as  they 
have  sanctioned  similarly  the  segregation  of  other  infectious,  pre- 
ventable disease  carriers,  public  authorities  and  private  agencies 
ahke  can  do  little  but  mark  time.  The  principles  underlying  the 
control  of  tuberculosis,  segregation,  supervision  and  adequate  re- 
lief have  been  recognised  for  a  decade.  There  has  been  lacking 
only  the  willingness  to  follow  the  application  of  these  principles 
through  to  its  logical  conclusion,  when  this  means  for  supervision 
and  relief,  largely  increased  appropriations  of  either  public  funds 
or  private  contributions,  or  for  segregation,  the  readjustment  of 
our  emotional  outlook  on  the  rights  of  the  individual. 


Part  I 

A  Comparative  Study  of  74  Relief  Families 
and  64  Non-Relief  Families 

NEW  YORK  CITY'S  register  of  tuberculous  individuals  is 
approximately  35,000.  The  annual  crop  of  new  patients 
averages  22,000  each  year.  Twenty-seven  thousand  six 
hundred  and  sixty-four  of  all  these  pass  through  the  clinics ; 
14,063  find  their  way  in  and  out  of  the  hospitals;  8,918  die. 

Excluding  the  amount  spent  by  subsidized  private  institutions 
over  and  above  the  per  capita  payments  made  to  them  by  the  City, 
we  can  summarize  the  annual  cost  ^  of  the  care  of  tuberculosis  to 
the  city  of  New  York  as  follows : 

INSTITUTIONAL    ( CHIEFLY    MEDICAL    CARE) 

By  the  City $1,730,262.96 

By  private  agencies   60,710.90 

$1,790,973.86 


HOME  CARE    ( MEDICAL  AND   SOCIAL 
AND   relief) 

By  the  City  .  . ., $377,31 1.09 

By  private  agencies 310,031.10 

687.342.19 

$2,478,316.05 

This  total  of  $2,478,316.05  represents  a  capital  investment  of 
$49,566,321.  Stated  in  other  terms,  if  the  annual  cost  of  tuber- 
culosis in  dollars  and  cents  were  distributed  upon  a  per  capita 
basis,  EVERY  MAN,  WOMAN  AND  CHILD  OF  THE  FIVE 
MILLION  AND  MORE  LIVING  IN  THE  GREATER  CITY 
OF  NEW  YORK  WOULD  BE  TAXED  FORTY-SIX  CENTS 
YEARLY. 


1  See  Appendix,  pages  76  and  ']'],  for  detailed  statement. 

5 


The  acid  test  for  determining  the  value  of  this  expenditure 
for  the  care  of  tuberculosis  is  to  be  found  in  the  death  rate, 
which,  as  we  know,  has  steadily  declined  year  by  year,  a  greater 
declination  than  has  occurred  in  the  general  death  rate  during 
the  same  time. 

INSTITUTIONAL   CARE   VS.    HOME   CARE 

For  testing  the  relative  value  of  the  two  methods  of  care  we 
have  as  yet  no  accurate  measuring  rod.  Many  factors  combine 
to  invalidate  morbidity  statistics.  The  true  incidence  of  tuber- 
culosis cannot  be  definitely  determined  until  we  are  sure  of  com- 
plete registration  returns.  We  are,  however,  pretty  thoroughly 
committed  to  the  institutional  form  of  treatment,  and  our  chief 
aim  should  be  to  use  this  method  in  the  most  intelligent  and  effi- 
cient way  in  order  to  secure  the  best  returns. 

A  certain  amount  of  home  care  seems  at  present  inevitable. 
Some  go  further  and  say  it  is  desirable.  Funds  to  support  this 
home  care  come  largely  from  private  sources,  either  general  re- 
lief agencies  or  special  tuberculosis  funds.  The  general  relief 
agencies  have  to  face  tuberculosis  as  one  of  the  complex  factors 
in  the  problem  of  dependence  which  they  are  trying  to  handle. 

The  wisest  expenditure  of  the  special  tuberculosis  funds  is 
still  a  matter  for  discussion.  It  was  with  the  hope  of  throwing 
some  light  upon  the  use  of  those  special  tuberculosis  funds,  raised 
by  auxiliaries  to  tuberculosis  clinics,  that  the  present  study  for 
the  Committee  on  Homes  was  undertaken.  As  we  know,  by  far 
the  largest  demands  made  upon  these  special  tuberculosis  funds 
are  for  relief.  The  character  of  the  homes  into  which  such  re- 
lief goes  is  naturally  of  particular  interest  to  the  almoners  of 
these  funds. 

The  various  forms  of  institutional  care  of  tuberculosis  are 
fairly  well  crystallized.  There  are  hospitals,  sanatoria,  homes 
and  preventoria.  Institutions  in  each  class  are  graded  according 
to  the  medical  and  social  type  of  case  they  are  to  receive,  and 
there  is  one  admitting  agency,  the  Flospital  Admission  Bureau, 
which  sets  the  standard  to  which  each  type  must  conform. 


There  are  as  many  forms  of  home  care  as  there  are  agencies 
furnishing  it  or  individuals  representing  these  agencies  doing  the 
actual  work.  It  is  not  the  aim  of  this  report  to  hold  a  brief 
for  either  form  of  care,  institutional  or  home,  as  opposed  to  the 
other.  To  do  so  in  our  present  stage  of  development  would  be 
to  court  unanswerable  arguments  from  either  side  proving  that 
€ach  and  both  are  indispensable  under  certain  conditions.  But 
it  is  a  plea  for  some  concerted  attempt  to  standardize  the  types 
of  home  care  on  a  basis  which  will  recognize  the  fundamental 
needs  and  limitations  of  these  dependent  families  in  which  tuber- 
culosis is  a  factor — or  in  these  tuberculous  families  who  have 
become  dependent,  according  to  the  point  of  view. 

HOME   CARE  DEPENDENT   ON   HOME   CONDITIONS 

Admitting  at  the  very  start  the  thousand  and  one  social  and 
economic  threads  with  which  the  medical  side  of  tuberculosis  is 
inextricably  interwoven,  we  must  nevertheless  realize  that  the 
prevention  and  control  of  tuberculosis  is  our  particular  task,  just 
as  the  prevention  and  cure  of  dependency  is  the  task  of  organized 
philanthropy,  or  the  improvement  of  work  conditions  the  task  of 
organized  labor.  In  the  long  run  we  shall  accomplish  far  more 
by  sticking  to  our  last.  At  certain  points  where  the  tasks  over- 
lap (vide  the  home  care  of  tuberculosis)  we  should  at  least  base 
our  treatment  on  a  common  knowledge  of  fact,  and  a  recognition 
of  mutual  responsibility. 

Home  care,  to  be  effective,  presupposes  a  knowledge  of  home 
conditions.  If  the  elemental  requisites  for  a  decent  home  are 
lacking,  the  time,  effort  and  money  expended  upon  home  care  of 
tuberculosis  cases  cannot  be  expected  to  produce  results.  That 
much  of  our  laboriously  raised  tuberculosis  funds  have  been  spent 
on  makeshift  families  in  makeshift  homes  is  equally  true,  which 
is  chiefly  responsible  for  the  present-day  discouragement  of  the 
almoners  of  these  funds.  For,  as  the  tuberculosis  work  has  been 
extended  and  new  cases  discovered,  the  demands  for  relief  have 
increased.  Where  it  has  not  been  possible  to  augment  such  a 
fund  it  has  been  spread  out  a  little  thinner  so  as  to  include  more 


recipients.  After  a  time  some  have  been  dropped  because  they 
would  not  respond,  because  they  seemed  hopeless,  because  nothing 
could  be  done  with  them,  or  for  them. 

STUDY  FOR   COMMITTEE   ON   HOMES 

Three  years  ago  a  joint  "Committee  on  Homes"  was  ap- 
pointed by  the  Committee  on  the  Prevention  of  Tuberculosis  and 
the  Association  of  Tuberculosis  Clinics  to  make  a  study  of  homes 
where  there  was  tuberculosis.  With  medical  records  of  clinics 
going  back  for  five  years  and  social  records  of  relief  agencies 
extending  back  indefinitely,  it  was  felt  that  a  study  of  these  rec- 
ords would  bring  to  light  facts  regarding  the  social,  economic 
and  physical  background  of  these  families  which  would  help  con- 
siderably in  arriving  at  a  diagnosis  of  the  underlying  causes  of 
their  condition  of  dependency  and  of  the  relation  of  tuberculosis 
thereto. 

Records  of  patients  were  taken  from  the  active  files  of  sev- 
eral clinics.  In  the  first  group  were  included  those  who  at  any 
time  since  admittance  to  the  clinic  had  received  aid  through  the 
clinic  or  auxiliary  relief  fund.  The  second,  or  control  group,  in- 
cluded those  who  had  never  received  relief  from  the  clinic  or  any 
known  relief  agency.  Eighty-one  clinic  patients  were  included  in 
the  former  group — seventy-nine  in  the  latter.  For  the  purpose 
of  this  study,  fractional  families  and  single  men  and  women  were 
excluded.  By  fractional  families  is  meant  other  than  normal 
families  of  parent  or  parents  and  children,  e.  g.,  a  man  and 
nephew,  a  deserted  woman  living  with  her  mother's  family. 

There  remained  74  families  who  were  known  to  have  re- 
ceived relief  and  64  who  had  never  been  known  to  receive  relief, 
and  who  will  hereafter  be  referred  to  as  non-relief  families. 
These  138  families  were  distributed  amongst  the  various  clinics 
as  follows :  the  74  relief  families  were  registered  at  the  follow- 
ing clinics:  Bellevue,  26;  H.  D.,  Chelsea,  32;  H.  D.,  Harlem  Ital- 
ian, 16.  The  64  non-relief  families  were  registered  at  the  follow- 
ing clinics:  Bellevue,  10;  H.  D.,  Chelsea,  2;  Mount  Sinai,  35,- 
Presbyterian,  15;  H.  D.,  Stuyvesant,  i;  St.  Luke's,  i. 

8 


The  preponderance  of  relief  families  in  certain  clinics  and 
non-relief  families  in  certain  others  should  not  be  ascribed  to  the 
racial  character  of  the  particular  district  covered  or  to  the  na- 
tionality of  the  family  studied,  the  detail  of  which  appears  later. 
The  relief  cases  at  the  clinics  mentioned  were  selected  for  study 
primarily  because  of  the  fact  that  organized  women's  auxiliaries 
attached  to  these  clinics  had  made  possible  more  extensive  relief 
work  for  these  particular  cases. 

The  study  of  these  relief  families  was  arbitrarily  discontin- 
ued with  the  completion  of  74  cases  because  of  the  large  amount 
of  work  involved.  The  selection  of  the  64  non-relief  families 
at  various  clinics  was  determined  chiefly  by  the  completeness  of 
the  records  available  for  such  families  and  the  length  of  time  they 
had  been  known  to  the  clinics. 

METHODS    OF    STUDY 

A  special  record  form  was  prepared  which  summarized  and 
classified  all  available  information  to  be  obtained  from  the  rec- 
ords of  the  clinic  and  the  social  or  relief  agencies.  The  housing 
conditions  past  and  present  were  noted,  the  physical  conditions 
past  and  present  of  each  member  of  the  family,  also  the  physical 
and  mental  defects,  work-history  and  earning  capacity  and  the 
kind,  source  and  extent  of  relief. 

The  information  from  the  clinic  record  was  obtained  by  the 
assistant  to  the  Executive  Secretary  of  the  Association  of  Tuber- 
culosis Clinics,  a  graduate  nurse  of  wide  experience  in  the  work 
of  the  tuberculosis  clinics  and  thoroughly  familiar  with  the  vari- 
ous types  of  patients  and  their  homes.  vShe  was  thus  capable  of 
interpreting  the  medical  data  on  the  clinic  records  and  was 
equally  alive  to  the  importance  of  noting  accurately  whatever 
social  and  economic  data  were  available  at  the  clinic. 

All  records  were  then  referred  to  the  Social  Service  Ex- 
change to  learn  what  other  agencies,  if  any,  had  known  these 
families,  and  records  of  the  social  agencies  were  obtained,  addi- 
tional information  contained  in  them  was  added  to  the  study  rec- 
ord, and  an  attempt  was  made  to  compare,  collate  and  finally 


summarize  for  each  family  the  facts  contained  in  the  records  of 
both  medical  and  social  agencies.  This  was  done  by  three  peo- 
ple, each  working  on  a  separate  group  of  relief  families,  the  Sec- 
retary of  the  Committee  on  the  Prevention  of  Tuberculosis,  a 
member  of  the  staff  of  the  School  of  Philanthropy  and  the  Execu- 
tive Secretary  of  the  Association  of  Tuberculosis  Clinics.  An 
additional  exhaustive  study  of  the  methods  of  social  care  was 
made  by  the  staff  member  of  the  School  of  Philanthropy  for  her 
particular  group  of  35  relief  families.  It  was  not  practicable  to 
extend  this  intensive  study  to  the  other  groups  of  relief  families 
owing  to  the  length  of  time  required,  but  it  seems  reasonable  to 
conclude  that  the  findings  for  this  group  are  equally  applicable 
to  the  other  groups. 

Whatever  conclusions  are  offered  as  a  result  of  this  study 
are  offered  as  indicating  tendencies  rather  than  as  arbitrary 
statements  of  fact.  Some  of  the  records,  both  medical  and  social, 
afforded  only  the  most  meagre  kind  of  information ;  others  were 
obviously  inaccurate;  other  voluminous  ones,  while  extending 
over  a  considerable  period^  yet  had  long  lapses  of  time,  when  the 
family  was  lost  sight  of,  and  during  which  there  was  no  recorded 
information  available. 

Certain  lines  of  inquiry  had  to  be  abandoned  in  the  final 
sum.mary  because  of  the  inadequacy  or  unreliability  of  the  facts 
noted  or  of  their  interdependence  on  certain  other  facts  which 
were  not  available.  Thus  the  information  as  to  the  amount  of 
institutional  care  was  of  little  or  no  value  because  it  was  so  ob- 
viously incomplete.  In  some  instances  depending  solely  on  the 
statement  of  the  family,  all  the  available  information  on  this 
point  was  complicated  by  the  fact  that  the  institutional  sojourn 
had  not  been  continuous,  patients  going  in  and  out  of  institu- 
tions two  or  three  or  more  times,  so  that  the  length  of  stay  had 
but  slight  bearing  on  the  final  outcome  so  far  as  the  individual 
patient  or  the  involvement  of  his  family  was  concerned.  The 
significant  fact  stood  out  boldly — the  casualness  of  the  institu- 
tional care  received  by  these  people. 

So  the  attempt  to  throw  any  light  on  the  question  of  house 
infection  had  to  be  abandoned  because  of  the  incompleteness  of 

10 


the  records,  few  recording  anything  more  than  the  number  of 
cases  occurring  in  a  given  house,  the  individual  apartment  being 
seldom  noted. 

The  social  and  economic  data  regarding  the  non-relief  fami- 
lies were  naturally  scanty,  the  clinic  record  being  the  sole  source 
of  information.  As  these  families  had  never  asked  aid  they 
had  been  chary  of  giving  information,  and  it  had  not  been  easy 
for  the  clinic  nurse  to  extract  it  along  these  lines.  Thus  again 
the  attempt  to  summarize  for  purposes  of  comparison  the  find- 
ings of  the  two  groups  of  relief  and  non-relief  families  was  lim- 
ited by  the  necessity  of  confining  such  a  summary  to  facts 
available  for  both  groups. 

OBJECTS    OF   THE    STUDY 

This  inquiry  had  four  objects: 

First :  To  show  the  background,  the  constitution,  the  quality 
of  fibre,  so  to  speak,  of  those  families  under  clinic  care  who  are 
regarded  specifically  as  tuberculous  families,  who  are  partially 
or  entirely  dependent  and  for  whom  special  tuberculosis  funds 
are  being  called  upon  to  furnish  material  relief. 

Second :  To  contrast  with  these  dependent  families  other 
families  under  clinic  care  who  thus  far  have  taken  care  of  their 
own  tuberculosis,  who  have  escaped  the  shoals  of  dependency,  in 
order  to  see  in  what  way  they  dififer  from  the  group  of  dependent 
families. 

Third :  To  point  out  deficiencies  in  both  the  medical  and 
social  treatment  of  dependent  families  with  tuberculosis. 

Fourth :  To  suggest  possibilities  for  the  employment  of 
special  tuberculosis  funds  which  will  bring  in  the  largest  ultimate 
returns. 

If,  in  our  study  of  methods  of  treatment,  undue  emphasis 
appears  to  have  been  put  upon  the  social  agencies'  technique  and 
the  medical  agencies  let  off  too  lightly,  it  should  be  remembered 
that  we  have  been  analyzing  and  criticising  the  professional  work 
of  our  medical  agencies  (or  clinics)   since  the  beginnings  of  the 

11 


Association  of  Tuberculosis  Clinics,  and  we  shall  continue  to  do 
so.  We  know  only  too  well  where  we  compromise  with  our 
ideals,  where  we  fail.  A  certain  social  responsibility  is  also  ours. 
A  knowledge  of  the  experience,  the  mistakes,  the  responsibilities 
of  others  will  help  us  to  a  clearer  vision  of  ourselves. 

SCOPE    OF   THE    STUDY 

Information  on  the  following  points  has  been  tabulated  and 
summarized  for  both  the  relief  and  non-relief  families : 

1.  Nationality. 

2.  Housing  Conditions. 

3.  Tuberculosis  History. 

4.  Status  of  Wage-Earners. 

5.  Occupation  and  Wages. 

6.  Income. 

For  the  relief  families,  the  period  covered  by  the  record  of  the 
social  agency  was  noted  as  well  as  the  character  of  relief  given, 
whether  it  was  temporary,  intermittent  or  continuous  for  any 
length  of  time. 

NATIONALITY 

The  nationality  of  the  two  groups  of  families  studied  ^  is 
given  as  a  matter  of  general  interest,  but  it  is  not  claimed  that 
it  bears  any  relation  to  the  general  incidence  of  tuberculosis 
throughout  the  city.  The  preponderance  of  certain  nationalities 
is  easily  traceable  to  the  character  of  the  district  in  which  the 
particular  chnic  was  located  from  which  the  clinic  records  were 
chosen.  Thus  the  Irish  and  the  American  born  characterize  the 
Chelsea  clinic  district  on  the  middle  west  side.  The  Italians  were 
found  chiefly  in  the  northeastern  portion  of  Manhattan,  known 
as  Little  Italy,  and  covered  by  the  Harlem  Italian  Clinic,  while 
all  three  nationalities  are  to  be  found  in  Bellevue  district.     The 


1  See  Appendix,  page  59. 

12 


Russians  were  found  principally  in  Mt.  Sinai  district,  the  uptown 
Hebrew  quarter.  In  the  majority  of  instances  both  the  father 
and  mother  were  of  the  same  nationality ;  where  they  were  of 
different  nationality  that  of  the  mother  was  noted. 

HOUSING 

The  relation  of  housing  to  tuberculosis,  while  generally 
acknowledged,  has  not  always  been  easy  to  define.  We  know 
that  bad  housing  conditions,  overcrowding,  insufficient  light  and 
air,  lower  physical  resistance  and  breed  disease.  We  know  that 
the  economic  strain  under  illness  breeds  poverty  and  lowers  the 
standard  of  living.  Cheaper  rents  usually  mean  poorer  living 
quarters,  so  that  bad  housing  follows  in  the  train  of  prolonged 
sickness.  Whichever  be  the  prime  factor,  granted  that  bad  hous- 
ing and  tuberculosis  are  both  present  in  a  given  case,  there  can 
be  no  question  as  to  the  danger  of  the  infection  spreading  to 
other  members  of  the  family.  It  is,  therefore,  pertinent  to  the 
present  inquiry  to  compare  the  housing  conditions  of  the  two 
groups. 

The  74  relief  families  comprise  425  individuals,  of  whom  164 
are  adults  and  261  (61%)  are  children  under  16. 

The  64  non-relief  families  comprise  321  individuals,  of  whom 
216  are  adults  and  105  (32^%)  are  children  under  16.  Rec- 
ognizing how  prone  to  infection  are  young  children  living  in 
contact  with  a  tuberculous  individual,  the  proper  housing  of  the 
group  of  relief  families  becomes  doubly  important  in  view  of  the 
fact  that  there  are  proportionately  nearly  twice  as  many  children 
under  16  in  this  group  as  in  the  non-relief  group. 

But  we  find  that  over  half  of  the  relief  families  are  living 
in  two-  and  three-room  apartments,  as  against  a  little  over  a 
fourth  of  the  non-relief  families  who  are  similarly  housed.^  The 
consequent  overcrowding  undoubtedly  falls  heaviest  upon  the 
children  in  the  relief  group.  If  horrible  examples  are  wanted 
they  may  be  had.    Thus  we  find  in  the  relief  group : 


1  See  Appendix,  page  60. 

13 


No.  of  No.  of 

Persons  per      Rooms  in 
Household      Apartment 

One  family,  Italian  8  2 

Two  families,  Hungarian  (living  together)  .  .  10  3 

One  family,  Italian  9  3 

One  family,  Italian  9  3 

One  family,  Italian  7  3 

One  family,  Italian  7  3 

One  family,  United  States 7  3 

One  family,  Italian  10  4 

One  family,  Italian 10  4 

One  family,  Irish 10  4 

In  the  non-relief  group : 

One  family,  Russian 7  3 

One  family,  Russian 7  3 

One  family,  Russian 8  4 

An  attempt  was  made  to  note  the  number  of  so-called  dark 
rooms.^  The  report  of  the  home  conditions  was  in  every  in- 
stance made  by  the  clinic  nurse,  who  is  usually  unfamiliar  with 
the  technical  legal  definition  of  a  dark  room.  Her  statement, 
however,  that  a  room  was  dark,  or  dim,  means  that  these  rooms 
in  her  opinion  were  unfit  for  ordinary  living  or  sleeping  pur- 
poses. As  these  reports  were  made  by  several  nurses,  variations 
in  standard  due  to  the  personal  equation  would  balance  each 
other. 

In  the  70  homes  of  relief  families  there  were  48  dark  rooms 
in  30  apartments.  In  the  63  homes  of  non-relief  families  there 
were  52  dark  rooms  in  28  apartments.  That  is,  425^%  of  the  re- 
lief families  were  exposed  to  the  danger  of  living  in  dark  rooms,  as 
against  44%  of  the  non-relief  families.  On  the  other  hand,  con- 
sidering the  total  number  of  rooms  occupied  by  each  group,  we 
find  that  20%  of  the  rooms  occupied  by  the  relief  families  were 
dark,  as  against  19%  of  those  occupied  by  the  non-relief  families, 
while  the  average  person  per  room  was  for  the  relief  families, 
1.8,  and  for  the  non-relief  group,  1.2. 

1  See  Appendix,  page  61. 

14 


Comparing  the  two  groups  according  to  the  size  of  the  apart- 
ment occupied/  we  find  that  over  50%  of  the  relief  famihes  were 
housed  in  2-  and  3-room  apartments,  33%  in  4-room  apartments, 
7%  in  5-room  apartments.  On  the  other  hand,  only  25%  of  the 
non-relief  families  were  living  in  2  and.  3  rooms,  43%  were  Hving 
in  4-room  apartments,  18%  in  s-room  apartments,  10%  in  6-room 
apartments,  3%  in  7-room  apartments.  Comparing  the  rentals^ 
paid  by  the  two  groups  for  the  same  size  apartment,  we  find  that 
the  non-relief  famihes  were  in  many  instances  paying  a  higher 
rental  for  the  same  size  apartment,  from  which  we  may  assume 
that  they  were  occupying  a  higher  grade  of  apartments. 

The  general  condition  of  the  homes  as  regards  their  cleanli- 
ness was  classified  as  Good,  Fair  and  Bad.^  Over  one-fifth  of 
the  homes  of  the  relief  families  were  characterized  as  Bad. 

From  the  nature  of  things  it  was  to  be  expected  that  self- 
supporting  families  would  be  living  under  better  housing  condi- 
tions than  dependent  famihes.  But  the  living  conditions  of  some 
of  the  relief  families  are  not  only  relatively  less  good,  they  are 
positively  bad.  The  futility  of  attempting  to  treat  tuberculosis 
in  homes  such  as  these  would  seem  to  be  self-evident. 

TUBERCULOSIS    HISTORY 

A  comparison  of  the  amount  of  known  tuberculosis  infec- 
tion existing  in  the  two  groups  of  families  *  brings  out  several 
significant  facts :  first,  the  much  greater  incidence  of  tuberculosis 
in  the  relief  families,  amounting  to  1.86,  as  against  1.17  in  the 
non-relief  families ;  second,  the  greater  number  of  wage-earners 
affected  in  the  relief  families,  31%  of  the  total  cases  in  these 
families  being  adult  males,  as  against  17.8%  of  the  cases  in  the 
non-relief  group — or,  comparing  the  number  of  wage-earners  hav- 
ing tuberculosis,  living  and  dead,  with  the  total  number  of  wage- 
earners  in  the  group,^  we  find  that  58%  in  the  relief  group  are 
or  have  been  tuberculous,  compared  with  21%  in  the  non-relief 

1  See  Appendix,  page  60. 
-  See  Appendix,  page  62. 

2  See  Appendix,  page  63. 

4  See  Appendix,  page  64. 

5  See  Appendix,  page  65. 

15 


group ;  third,  the  proportionately  larger  number  of  women  and 
adult  children  with  tuberculosis  in  the  non-relief  group;  fourth, 
the  large  number  of  children  under  i6  in  the  relief  group  who 
have  become  infected,  as  contrasted  with  the  negligible  number 
infected  in  the  non-relief  group. 

But  the  story  is  only  half  told  until  we  add  the  facts  regard- 
ing the  thoroughness  with  which  the  physical  examination  of  the 
families  has  been  made.^ 

It  would  appear  that  the  medical  supervision  over  the  relief 
families  is  much  closer  than  over  the  non-relief  families,  inas- 
much as  only  20%  of  the  individuals  in  the  former  group  have 
not  been  examined,  while  65^%  in  the  latter  group  have  not 
been  examined.  Our  previous  assumption  as  to  the  extent  of 
tuberculosis  in  these  families  must  therefore  be  modified  by  our 
ignorance  as  to  the  real  physical  condition  of  these  individuals 
who  have  never  been  examined.  Presumably,  all  definitely  ill  per- 
sons were  detected,  but  the  amount  of  preventive  work  which 
might  have  been  done,  particularly  in  the  non-relief  families,  is 
clearly  evidenced  by  the  large  proportion  of  children  under  16 
who  have  never  been  examined. 

EFFECT  OF  TUBERCULOSIS  ON  ECONOMIC  STATUS 

Classifying  the  families  according  to  the  tuberculosis  con- 
dition or  status  of  the  wage-earners^  we  find  that  35%  of  the 
relief  families  were  widows'  families,  as  against  14%  of  the  non- 
relief  families  (including  two  families  where  the  man  was  a 
deserter).  Coupled  with  this  fact  is  the  additional  handicap  un- 
der which  the  relief  families  are  laboring;  viz.,  that  in  43.7%  of 
the  families  where  the  man  is  living  he  is  ill  with  tuberculosis,  as 
compared  with  21.8%  of  the  non-relief  famihes  where  the  man 
is  living. 

Summarizing  the  work  history  of  the  members  of  the  two 
groups  ^  we  find  that  in  the  21  relief  families  where  the  man  is 
living  only  4  men  are  working  at  the  same  occupation  with  the 

1  See  Appendix,  page  66. 
~  See  Appendix,  page  65. 
3  See  Appendix,  page  67. 

16 


same  wage  as  formerly,  while  7  are  not  working,  and  the  remain- 
ing 10  are  working  irregularly  at  less  remunerative  jobs;  17 
women  are  supplementing  the  family  income  by  doing  unskilled 
work,  chiefly  cleaning,  at  an  average  wage  of  from  $4.00  to  $6.00 
weekly.  Seven  of  these  women  are  themselves  tuberculous,  as 
are  3  of  the  remaining  4  who  are  not  working.  In  the  12  non- 
relief  families  where  the  man  is  living,  3  are  not  working  and  3 
are  working  irregularly.  Information  is  too  meagre  to  attempt 
a  comparison  with  their  previous  earning  capacity  for  the  remain- 
ing 6.  Only  I  woman  in  these  12  families  is  working  as  janitress 
with  rent  free.  Only  i  woman  was  tuberculous  and  she  is  dead. 
In  5  of  these  families  the  income  is  supplemented  by  adult  chil- 
dren who  are  working,  2  of  whom  are  tuberculous. 

In  the  22  relief  families  where  the  man  is  dead  from  tuber- 
culosis, 15  women  are  working,  6  of  whom  are  tuberculous.  In 
addition,  3  women  who  are  not  working  are  tuberculous.  One 
woman  is  dead  from  tuberculosis.  Six  of  the  families  have  7 
adult  children  working,  while  3  children  under  16  in  these  fam- 
ilies are  also  contributing  to  the  support  of  the  family,  i  of  whom 
is  tuberculous.  In  the  non-relief  families  where  the  man  has 
died  from  tuberculosis,  i  woman  is  tuberculous  and  2  adult  chil- 
dren are  working,  i  of  whom  is  also  tuberculous. 

In  those  families  where  the  man  is  living  and  not  tuberculous, 
we  find  in  the  27  relief  families  19  of  the  women  tuberculous,  2 
of  whom  are  dead.  Fourteen  are  working,  9  of  whom  are 
tuberculous.  In  8  families  the  income  is  supplemented  by  the 
children's  work. 

In  the  43  non-relief  families,  all  but  10  of  the  women  are 
tuberculous.  Six  only  are  working,  5  of  whom  are  tuberculous. 
In  18  families  the  income  is  supplemented  by  the  children's  work, 
all  adults  with  one  exception.  Five  other  adult  children  are 
tuberculous  and  not  working. 

In  the  families  where  the  cause  of  the  man's  death  is  un- 
known or  he  has  deserted,  we  find  in  the  4  relief  families  3  of  the 
women,  although  tuberculous,  are  working;  also  i  adult  child 
who  is  tuberculous.     In  the  8  non-relief  families  4  of  the  women 

17 


are  tuberculous,  2  of  whom  are  working.  In  6  families,  13  adult 
children  are  working,  5  of  whom  are  tuberculous.  Three  other 
adult  children  are  not  working  and  are  tuberculous. 

It  would  seem  that  the  economic  pressure  is  greatest  upon 
the  women  in  the  relief  families,  many  of  whom  are  tuberculous, 
and  upon  the  adult  children  in  the  non-relief  families.  In  the 
first  instance,  this  means  that  the  children  in  these  families  are 
likely  to  suffer  both  physical  and  moral  handicap  because  of  their 
exposure  to  infection  and  lack  of  proper  care.  In  the  second 
instance,  it  means  that  adolescent  children,  young  men  and  young 
women,  constitute  the  barrier  between  their  families  and  semi- 
dependency,  and  are  enduring  a  strain  under  which  some  have 
already  broken  and  which  may  result  in  the  ultimate  break-down 
of  these  others. 

OCCUPATION   AND   WAGES 

It  would  seem  natural  to  suppose  that  a  higher  earning 
capacity  in  the  non-relief  families  had  insured  a  standard  of 
living  sufficient  to  enable  them  to  take  care  of  their  own  tubercu- 
losis, but  one  of  the  most  interesting  and  unexpected  facts 
brought  out  by  a  comparative  study  of  the  occupation  and  wages 
of  the  relief  and  non-relief  families  is  that  both  belong,  generally 
speaking,  to  the  same  wage-earning  groups. 

Classifying  the  families  according  to  the  wages  of  the  man, 
whether  living  or  dead,^  we  find  that  in  over  half  the  families 
in  either  group  the  man  earned  less  than  $15.00  per  week — in 
63^/2%  of  the  relief  families,  in  59%  of  the  non-relief  families. 
In  the  former  group,  in  12%  of  the  families  the  man  earned 
$15.00,  in  9%  over  $15.00.  For  the  remaining  famihes  (15%) 
no  information  was  available.  In  the  non-relief  group,  one  only 
was  said  to  have  earned  $15.00  per  week;  9%  were  earning  over 
$15.00.  In  over  one- fourth  of  the  famihes  (29%),  no  informa- 
tion was  available.  Presumably  their  earning  capacity  was  over 
$15.00  per  week.  In  four  of  these  it  is  known  that  the  men 
were  owners  or  part  owners  of  stores  or  shops.     The  question 

1  See  Appendix,  page  68. 

18 


of  regularity  of  employment  has  not  been  considered,  owing  to 
the  lack  of  sufficient  data.  That  in  many  instances  the  income 
from  the  man's  work  was  neither  regular  nor  sufficient  may  be 
inferred  from  the  large  number  of  families  with  the  man  living 
in  which  the  income  was  supplemented  by  the  work  of  women 
and  children  under  i6. 

The  income  from  the  work  of  adult  children  ^  has  evidently 
contributed  materially  towards  the  maintenance  of  the  economic 
independence  of  45%  of  the  non-relief  families.  Thus  we  find, 
out  of  a  total  of  64  adult  working  children  living  in  29  families, 
31%  are  earning  under  $10.00,  21%  earning  from  $10.00  to 
$14.00,  5%  earning  $15.00,  and  9%  earning  over  $15.00.  Twelve 
per  cent,  who  have  formerly  worked  are  no  longer  working, 
seven  of  whom  are  tuberculous.  Twelve  of  those  who  are 
working  are  also  tuberculous.^  No  information  was  available 
regarding  20%  who  are  known  to  be  working. 

In  21  relief  families,  25  adult  children  are  working,  20  of 
whom  are  earning  under  $10.00  per  week.  No  information  was 
available  regarding  the  remaining  5.  Four  of  the  adult  work- 
ing children  in  this  group  are  also  tuberculous. 

The  classification  of  occupations  into  skilled  and  unskilled 
has  been  more  or  less  arbitrary.  Under  the  former  classification 
was  included  the  various  tailoring  processes,  the  trades,  such  as 
painters,  carpenters,  stonemasons,  plumbers,  horseshoers,  fac- 
tory hands,  clerks  and  bookkeepers,  chauffeurs,  electricians,  etc. 
Under  the  latter  was  included  peddlers,  laborers,  drivers,  porters, 
longshoremen,  waiters,  etc. 

No  attempt  was  made  to  classify  the  work  done  by  women. 
In  the  relief  group  49  women,  with  few  exceptions,  were  doing 
laborious  unskilled  work — washing,  office  cleaning  and  janitress 
work.  The  highest  weekly  wage  was  $9.00  for  cleaning.  The 
average  wage  was  from  $3.00  to  $6.00.  One  woman  worked 
on  artificial  flowers,  earning  $1.00  weekly;  3  on  feathers,  earn- 
ing from  $3.00  to  $4.00  weekly;  5  worked  in  factories,  earning 
from  $3.00  to  $6.00. 


1  See  Appendix,  page  68. 
-  See  Appendix,  page  67. 


19 


In  the  non-relief  group,  only  9  women  were  working,  4  as 
janitress,  2  at  cigar-making,  i  as  a  milliner,  i  at  photography 
and  I  sewed,  the  highest  weekly  earnings  amounting  to  $8.00. 

Of  the  II  children  under  16  in  the  relief  families  who  were 
working,  i  with  tuberculosis  was  working  as  a  farm  hand  for 
$1.00  a  week  and  his  board,  another  as  an  electrician  at  $4.00  a 
week,  I  in  a  factory  at  $5.00  per  week.  This  was  the  highest 
wage  earned  in  the  group.  The  others  were  shining  shoes,  sell- 
ing papers,  or  working  as  office  or  errand  boys. 

It  is  evident  that  the  pressure  of  dependency  has  forced  these 
women  and  children  to  take  up  the  burden  of  family  support, 
but  nearly  one-half  of  these  women  are  themselves  tuberculous. 
In  nearly  15%  of  these  families,  children  under  16  are  working. 
They  have  been  exposed  to  infection,  their  resistance  to  disease 
has  been  impaired  by  unfavorable  living  conditions  and  they  go 
into  a  dead-end  job  for  the  sake  of  the  $3.00  or  $4.00  they  can 
earn  to-day.  From  such  sowing  do  we  reap  our  harvest  of 
"cases"  as  the  years  go  by. 

In  the  64  non-relief  families  only  i  child  under  16  was  work- 
ing as  an  office  boy  and  he  was  tuberculous.  But  19,  nearly 
one-third  of  the  64  adult  working  children  in  this  group,  are 
tuberculous,  7  of  whom  have  already  dropped  out  of  the  ranks 
of  active  workers.  The  occupations  and  wages  of  the  12  who 
continue  to  work  are  as  follows : 

Occupation  Weekly  Wage 

Seamstress    $4.00 

Messenger    4.00 

Factory  Hand   6.00 

Fur   Worker    ■ 8.00 

10.00 

Laborer 10.00 

Bookkeeper    10.00 

Unknown    14.00 

Clerk   1 5.00 

P.  O.  Clerk   18.00 

20 


Occupation  Weekly  Wage 

Operator Unknown 

Factory  Hand    

Of  the  7  who  are  no  longer  working: 

Dentist's  Ass't $5.00 

Stenographer 10.00 

Clerk   18.00 

Stone  Cutter    Unknown 

Silversmith    

Factory  Hand    

Dressmaker    " 

One  is  at  a  loss  whether  to  congratulate  the  relief  families 
on  the  earning  capacity  of  their  women  and  children,  which 
has  not  sufficed,  however,  to  keep  them  from  the  shoals  of  de- 
pendency, or  to  congratulate  the  non-relief  families  on  their  suc- 
cess in  escaping  those  same  shoals ;  albeit,  in  some  instances  the 
price  of  escape  is  being  paid  in  part  by  the  work  of  tuberculous 
young  men  and  women. 

INCOME 

An  attempt  was  made  to  compare  the  incomes  of  the  two 
groups  of  families.  In  the  relief  group  67%  of  the  families 
had  an  income  of  less  than  $15,  of  whom  16.4%  were  under  $5. 
For  26%  the  income  was  from  $5  to  $10,  24%  from  $10  to  $15, 
17.8%  from  $15  to  $20,  5.4%  from  $20  to  $25;  for  5.4%  the 
income  was  not  known.  For  the  non-relief  group  the  income 
stated  for  38%  was  under  $15,  for  14.3%  from  $15  to  $20,  for 
14%  from  $20  to  $25.  Eleven  per  cent,  showed  an  income  be- 
tween $25  and  $30,  4.7%  from  $30  to  $39,  2%  over  $50.  For 
14%  no  information  was  available.  The  detail  of  this  com- 
parison classified  according  to  the  size  of  the  family  will  be  found 
in  the  table  on  page  69  of  the  Appendix. 

21 


It  should  be  borne  in  mind  that  the  incomes  stated  are  only 
approximate.  In  the  relief  families  they  may  be  considered  fairly 
accurate.  In  the  non-relief  families  it  was  naturally  much  more 
difficult  to  obtain  a  definite  statement  of  the  families'  resources, 
when  no  financial  aid  was  asked  or  desired.  In  some  instances  the 
minimum  income  stated  is  manifestly  inaccurate.  No  family 
could  live  on  such  an  income.  No  further  information  was 
available,  however. 

The  size  of  family  includes  only  those  living  and  being  sup- 
ported in  the  home — members  of  families  in  institutions  are  not 
included. 

This  statement  of  income  has  been  arrived  at  by  adding  the 
wages  of  all  working  members  of  a  family  living  at  home,  to- 
gether with  the  amount  received  from  lodgers  and  boarders. 
There  were,  however,  very  few  of  the  families  supplementing 
their  income  in  this  way,  seven  relief  families  and  six  non-relief 
families  in  all.  There  was  no  available  information  regarding  the 
income  of  four  relief  families  and  eight  non-relief  families.  For 
the  relief  families  where  the  income  is  stated  as  nothing,  the  fam- 
ilies were  receiving  pensions  from  some  relief  agency,  which  is 
also  true  of  several  families  where  the  stated  income  was 
ridiculously  low.  For  the  relief  families  it  represents  at  most  the 
limit  of  their  wage-earning  capacity  rather  than  their  average 
income,  for  this  estimate  takes  no  account  of  irregularity  of  em- 
ployment and  the  complicating  personal  factors  of  alcoholism, 
ill-health  or  inefficiency. 

LENGTH  OF  SOCIAL  HISTORY  VS.  LENGTH  OF 
TUBERCULOSIS  HISTORY 

Assuming  that  the  beginning  of  the  social  and  economic  ills 
of  the  relief  families  was  coincident  with  their  first  application 
to  the  organized  relief  agencies,  an  interesting  comparison  can 
be  drawn  between  the  length  of  time  covered  by  their  tubercu- 
losis history  as  shown  by  the  clinic  record  and  the  period  covered 
by  the  history  of  their  social  maladjustment  as  shown  by  records 

22 


of  the  social  agency.^  It  is  also  significant  to  compare  the  non- 
relief  families  with  the  relief  families  as  to  the  duration  of  their 
tuberculosis  clinic  history. 

Ten,  or  133^%,  of  the  relief  families  were  unknown  to  the 
organized  relief  agencies  at  any  time.  Whatever  material  relief 
had  been  given  to  them  had  come  either  through  the  clinic  or 
from  some  private  or  personal  source,  such  as  the  church,  rela- 
tives, foreign  benevolent  associations,  etc.  Of  the  remaining 
86%  no  material  relief  had  been  given  by  organized  relief  agen- 
cies to  8j4%  ;  155^%  had  received  temporary  relief,  45%  inter- 
mittent relief,  31%  continuous  relief. 

Nearly  one-half,  48%,  had  been  known  to  the  organized  social 
agencies  over  3  years,  12%  had  been  known  to  these  agencies 
from  8  to  21  years.  The  tuberculosis  history  of  61^  %  of  these 
families,  however,  covered  a  period  of  3  years  or  less,  another 
25%  had  been  known  to  the  clinics  from  3  to  4  years,  while  the 
remaining  13%  had  been  known  to  the  clinics  from  5  to  8  years. 

Comparing  the  length  of  the  tuberculosis  history  of  the  non- 
relief  families  we  find  that  one-fourth  have  been  known  to  the 
clinics  under  6  months,  40%  from  6  months  to  2  years,  11% 
from  2  to  3  years.  Thus,  76%  had  been  known  to  the  clinics  three 
years  or  less  as  against  61%  of  the  relief  families  who  had  been 
known  to  clinics  for  a  similar  period.  A  still  more  significant 
contrast  is  found  in  the  number  known  to  the  clinics  for  a  period 
of  one  year  or  less,  42%  of  the  non-relief  families  as  compared 
with  113/2%  of  the  relief  families. 

As  the  burden  of  their  tuberculosis  extends  through  the  years 
to  come,  will  these  non-relief  families  join  the  ranks  of  semi- 
dependency  or  will  they  continue  to  be  saved  therefrom  by  their 
productive  children?  On  the  other  hand,  as  the  wage-earning 
children  in  the  relief  families  grow  to  maturity,  will  they  re- 
establish the  economic  independence  of  their  families  or  are  these 
families  permanently  and  irredeemably  subnormal  mentally  and 
physically  ? 

1  See  Appendix,  page  70. 

23 


SUMMARY 

Summarized  briefly,  the  findings  of  the  comparative  study 
of  relief  and  non-relief  families  were : 

1.  That  the  relief  families  show : 

a.  Poorer  housing  conditions. 

b.  A  longer  tuberculosis  history. 

c.  A  greater  incidence  of  infection. 

d.  A  larger  proportion  of  wage-earners  with  tu- 

berculosis, both  living  and  dead. 

e.  A  larger  proportion  of  women  working  and 

tuberculous, 
f.  A  larger  number  of  children  under  i6  with  a 
proportionately  greater  number  infected  with 
tuberculosis. 

2.  The  two  groups,  both  relief  and  non-relief  families, 

belong  to  the  same  wage-earning  class  with  few 
exceptions. 

3.  The  non-relief  group  shows : 

a.  A  much  larger  number  of  adult  children  in- 

fected   with    tuberculosis,    the    majority    of 
whom  are  or  have  been  working. 

b.  A  larger  income,  due  chiefly  to  the  work  of 

these  adult  children. 

4.  Eighty-six  per  cent,  of  the  relief  families  have  been 

known  to  various  relief  agencies  for  periods  ex- 
tending from  6  months  to  21  years,  of  whom  81/2% 
had  received  no  relief,  i5>^%  had  received  tem- 
porary relief,  45%  intermittent  rehef,  31%  con- 
tinuous relief. 

AVe  have  thus  accomplished,  so  far  as  was  feasible,  one  ob- 
ject for  which  the  present  inquiry  was  undertaken,  namely,  "to 
contrast  with  dependent  or  semi-dependent  families  under  clinic 
care  other  families  also  under  clinic  care  who  thus  far  have  taken 
care  of  their  own  tuberculosis  and  have  escaped  the  shoals  of 

24 


dependency  in  order  to  see  in  what  way  they  differ  from  the 
group  of  dependent  famiHes." 

The  intensive  study  of  thirty-five  reHef  cases  which  follows 
has  for  its  purpose  the  accomplishment  of  two  other  objects, 
stated  previously,  as  reasons  for  undertaking  the  inquiry : 

First,  "To  show  the  background,  the  constitution,  the  quality 
of  fibre,  so  to  speak,  of  those  families  under  clinic  care  who  are 
regarded  specifically  as  tuberculous  families,  who  are  partially,  or 
entirely  dependent,  and  for  whom  special  tuberculosis  funds  are 
being  called  upon  to  furnish  material  relief." 

Second,  "To  point  out  deficiencies  in  both  the  medical  and 
social  treatment  of  dependent  families  with  tuberculosis." 

The  accomplishment  of  the  fourth  object  of  the  inquiry, 
namely,  "to  suggest  possibilities  for  the  employment  of  special 
tuberculosis  funds  which  will  bring  in  the  largest  ultimate  re- 
turns," will  be  made  easier  if  predicated  on  the  findings  of  the 
inquiry  as  a  whole. 


25 


Part  II 

Intensive  Study  of  Thirty-Five  Relief  Families 

THIRTY-FIVE  families  receiving  aid  from  the  Woman's 
Auxiliary  of  one  of  the  Associated  Clinics  furnished  the 
basis  for  this  study.  These  families  had  been  selected  by 
the  Auxiliary  from  among  the  individuals  under  clinic  care  as 
most  in  need  of  relief  to  supplement  their  incomes.  Families 
unknown  to  other  social  agencies,  families  under  care  of  social 
agencies  but  not  receiving  adequate  relief  in  the  opinion  of  the 
visiting  clinic  nurse,  and  cases  in  which  the  Auxiliary  was  co- 
operating with  some  other  agency  in  the  matter  of  relief  were 
included.  Not  alone  those  with  the  smallest  income  but  those 
least  efficient  in  meeting  the  problem  of  life  and  living  are  to  be 
found  in  this  group.  On  the  other  hand,  casual  patients,  drift- 
ing in  and  out  of  the  clinic,  only  to  be  lost  sight  of  in  the  end,  did 
not  come  within  the  scope  of  the  Auxiliary's  work.  We  have, 
then,  a  selected  group,  which  includes,  however,  all  the  families 
under  Auxiliary  care  at  a  given  time. 

The  35  families  studied  include  31  normal  families,  i.  e., 
man,  woman  and  children;  2  fractional  families,  one  a  deserted 
woman  and  4  children  living  with  another  man,  and  a  woman 
living  with  her  mother  and  sister;  also  2  single  women.  There 
were  34  men,  37  women,  15  adult  children  and  131  children 
under  16  comprised  in  the  entire  group. 

Of  these  35  families  all  but  3  are  on  the  records  of  one  or 
the  other  of  the  large  organized  relief  societies.  Nineteen  of 
these  families  were  known  to  social  agencies  before  they  came  in 
contact  with  the  clinic. 

Problems  arising  from  ignorance  of  our  language,  our  cus- 
toms and  the  standards  necessary  for  city  life  bulk  large  in  the 
task  of  social  work  with  tuberculosis  patients.  The  fact  that 
these  problems  are  not  featured  in  this  study  means  only  that  in 
the  section  of  the  city  studied  the  families  were  predominately  of 

27 


American,  German  and  Irish  descent.  The  detail  of  the  nation- 
aHty  of  the  35  families  studied  is  as  follows :  United  States,  22 
(i  colored);  Italian,  4;  Irish,  6;  English,  i;  Polish,  i;  and 
Croatian,  i. 

Considering  the  occupation  of  the  wage  earners  of  these  fami- 
lies, the  predominance  of  drivers  and  laborers  has  no  relation  to 
their  tuberculous  condition,  but  rather  reflects  the  fact  that  a 
large  proportion  of  men  living  in  this  particular  section  of  the 
city,  the  middle  West  Side,  belong  to'  the  lowest  wage-earning 
group  and  are  either  teamsters  or  laborers. 

It  is  also  worth  noting  that  the  people  living  in  this  district 
are,  according  to  New  York  standards,  a  fairly  static  group,  fami- 
lies remaining  in  this  neighborhood  from  one  generation  to  an- 
other. When  they  do  move  the  new  home  lies  within  a  few  blocks 
of  the  old  one.  We  may,  therefore,  expect  to  see  the  neighbor- 
hood influences  reflected  in  the  lives  of  these  families.  The  char- 
acter of  these  neighborhood  influences  is  vividly  described  in  one 
of  the  "West  Side  Studies,  Boyhood  and  Lawlessness" : 

"At  first  sight  there  are  no  striking  features  about  the 
middle  West  Side.  Hand  to  mouth  existence  reduces  living 
to  a  universal  sameness,  which  has  little  time  or  place  for 
variety.  In  street  after  street  are  the  same  crowded,  unsani- 
tary tenements,  the  same  untended  group  of  playing  children, 
the  same  rough  men  gathered  around  stores  and  saloons  on 
the  avenue,  the  same  sluggish  women  grouped  on  the  steps 
of  the  tenements  and  the'  cross  streets.  The  visitor  will  find 
no  rambling  shacks,  no  conventional  criminal's  alleys — only 
square,  dull,  monotonous  ugliness,  much  dirt  and  a  great 
deal  of  apathy.  The  very  lack  of  salient  features  is  the  su- 
preme character  of  this  neighborhood.  The  most  noticeable 
fact  about  it  is  that  there  is  nothing  to  notice.  It  is  ear- 
marked by  negativeness.  There  is  usually  a  lifelessness 
about  the  streets  and  buildings,  even  at  their  best,  which  is 
reflected  in  the  attitude  of  the  people  who  live  in  them.  The 
whole  scene  is  dull,  drab,  uninteresting,  totally  devoid  of  the 
color  and  picturesqueness  which  give  so  many  poor  districts 
a  character  and  fascination  of  their  own." 

28 


STUDY  BASED  ON  MEDICAL  AND  SOCIAL 
RECORDS 

The  present  study  was  undertaken  jointly  by  a  nurse  and  a 
social  worker.  Unfortunately  for  the  completeness  of  the  study, 
the  medical  data  were  largely  collected  before  the  social  worker 
began  her  work,  and  only  in  a  few  puzzling  instances  did  it  seem 
worth  while  to  go  over  the  ground  a  second  time.  Thus  some  data 
which  might  have  been  available  in  the  medical  records  and  which 
seemed  important  to  a  social  worker  were  not  included  in  the  tabu- 
lation, usually  because  getting  it  would  necessitate  a  great  deal 
of  extra  labor  and  extend  the  scope  of  the  study  too  far  to  be 
practicable.  The  information  obtained  was  collected  from  many 
different  sources  with  infinite  pains,  e.  g.,  from  clinic  records  and 
nurses  (where  verbal  reports  could  be  relied  on  to  be  fairly  ac- 
curate), from  the  Hospital  Admission  Bureau,  and  from  the  main 
office  of  the  Department  of  Health. 

Theoretically,  the  records  of  each  patient  are  centralized  in 
one  place,  but  as  the  patient  is  sent  from  clinic  to  day  camp,  from 
day  camp  to  hospital  or  sanatorium  and  back,  perhaps  to  a  clinic 
in  a  different  section  of  the  city,  and  finally  is  discharged,  the  con- 
necting link  between  the  various  records  is  often  broken,  and  be- 
yond the  clerical  continuity  there  is  none,  each  agency  in  turn 
assuming  responsibility.  Often  the  clue  to  a  part  of  the  medical 
history  was  found  only  by  chance  in  the  social  record,  and  was 
then  traced  and  verified  by  applying  directly  to  the  agency  or 
institution  mentioned. 

In  several  of  the  clinics  the  records  of  the  several  members 
of  the  family  have  been  gathered  together,  so  that  if  you  know 
that  one  child  is  under  clinic  care  and  get  his  record,  you  can 
readily  find  out  all  about  the  other  children  as  well  as  about  the 
mother  and  father;  but  unfortunately  this  method  has  not  yet 
been  started  in  the  clinic  in  which  this  study  was  made. 

The  filing  systems  in  the  various  clinics  differ,  some  being 
by  name,  some  by  number,  some  by  the  day  of  the  week  the  case 
attends  the  clinic.  A  great  deal  of  information,  probably  the 
most  valuable,  is  stored  in  the  minds  of  physicians  and  nurses. 

29 


The  record-keeping  of  social  agencies,  on  the  other  hand,  is 
fuller,  more  continuous,  everything  known  of  one  family  being 
collected  in  one  envelope,  so  that  the  social  records  were  easier  to 
handle  and  more  nearly  a  measure  of  the  work  actually  done  by 
the  agency.  However,  social  data  which  seemed  important  soon 
exceeded  the  provisions  made  for  its  tabulation  on  the  printed 
schedule  prepared  for  use  in  connection  with  this  study.  An- 
other form  of  tabulation  was  prepared  which  allowed  for  the 
following  additional  classifications : 

1.  Calibre  of  family — Family  history — Attitude. 

2.  Home  surroundings  —  Healthful  stimuli  —  Freedom 

from  mental  strain. 

3.  Physical  complications. 

4.  Emiployment. 

5.  Income  vs.  Budget. 

6.  Needs  summarized. 

7.  Social  treatment  summarized. 

8.  Medical  treatment. 

9.  Family's  reaction  under  treatment. 

10.  Co-operation  of  clinic  and  social  agencies — Occa- 
sional reports — ^Joint  plan — Separate  treatment. 
The  roughness  of  these  headings  reflects  the  scrap-basket 
nature  of  this  schedule ;  but  in  one  way  or  another  a  great  many 
of  the  facts  which  were  used  in  later  tabulation  could  be  noted 
here,  and  also  unclassifiable  facts  and  even  impressions  which 
would  never  reduce  to  statistics,  but  too  telling  to  discard,  could 
be  lodged  in  this  scheme. 

PHYSICAL  DISABILITIES 

Any  consideration  of  the  physical  handicaps  under  which 
these  families  were  laboring  would  naturally  give  first  place  to 
the  amount  of  tuberculosis  from  which  they  were  suffering.  Out 
of  a  total  of  217  individuals,  54  (24.8%)  were  tuberculous,  of 
whom  20  (37%)  were  dead.^  Of  these,  five  tuberculous  children 
registered  in  the  social  records  but  not  in  the  clinic  records,  may 
have  died  before  the  family  came  to  the  attention  of  the  clinic. 
1  See  Appendix,  page  71. 

30 


It  appears  that  the  examination  of  other  members  of  the  family- 
has  been  fairly  well  carried  out,  as  only  38  (17.5%)  were  not 
examined. 

As  regards  other  physical  disabilities  not  directly  connected 
with  or  relating  to  the  tuberculous  infection  of  these  people  both 
the  medical  and  social  records  afford  only  the  most  meagre  infor- 
mation. Minor  illnesses  recorded  in  the  social  records,  unless  very 
frequent  or  noted  as  symptoms  of  more  serious  conditions,  were 
not  considered.  These  facts  are  brought  out  later  in  the  sum- 
mary of  physical  and  social  disabilities  (page  37,  part  II). 

An  attempt  was  made  to  tabulate  the  general  health  condi- 
tions under  the  headings  Good,  Poor,  Not  Stated,  but  it  seemed 
impracticable  because  of  the  slight  evidence  available. 


SOCIAL  DISABILITIES 

The  economic  status  of  these  families  and  its  relation  to  their 
tuberculous  condition  is  evidenced  by  the  information  obtained 
from  the  social  histories  regarding  their  condition  of  dependency. 
Thus  we  find  that  of  the  35  families : 

Three  were  not  known  to  organized  charity  ; 

Nineteen  were  known  to  organized  charity  previous  to 

clinic  care; 
Five  were  known  to  organized  charity   subsequent  to 

cHnic  care; 
Eight  were  known  to  organized  charity  and  to  the  clinic 

at  the  same  time. 

That  is,  19  families  had  a  previous  history  of  social  de- 
pendence, although  not  necessarily  receiving  relief.  In  eight 
families  social  dependence  developed  at  the  time  of  physical 
breakdown.  Five  families  were  able  to  meet  the  problem  for  a 
time  with  the  help  of  the  clinic,  but  later  needed  social  care. 
Three  families  have  so  far  been  helped  solely  by  the  clinic.  Doubt- 
less a  much  larger  proportion,  of  whom  we  have  no  record  be- 
cause they  do  not  come  within  the  scope  of  this  study,  carry  the 

31 


burden  of  sickness  with  no  help  from  either  organized  charity 
or  the  chnic. 

These  figures  are  suggestive  in  showing  in  how  few  famihes 
the  cHnics  try  to  carry  the  relief  problem  alone.  Of  three  fam- 
ilies in  this  group,  one  was  a  normal  family,  with  both  parents 
and  three  children.  There  are  indications  that  the  problem  was 
predominantly  a  health  problem.  The  man,  a  watchman,  was  in 
the  habit  of  making  $17  per  week.  There  are  no  mental  or 
moral  disabilities  recorded,  and  relatives  are  helping  the  family. 
The  danger  signals  indicated  are  that  it  is  the  man,  the  wage 
earner,  who  is  ill  and  incapacitated  for  work.  His  condition  is 
progressive  and  he  is  in  the  hospital.  The  relatives  are  "unable 
to  help  much."  The  family  is  unwilling  to  attend  clinic.  So  far 
it  is  apparently  a  family  meeting  its  own  problem,  although  not 
entirely  satisfactorily. 

The  other  two  included  in  this  group  are  single  women,  one 
of  whom  is  taken  care  of  by  the  community  through  a  sana- 
torium. The  other  lives  with  a  sister  and  their  old  mother,  appar- 
ently managing  with  very  little  help.  These  would  seem  to  be 
less  urgent  cases  from  a  social  point  of  view. 

That  eight  families  did  not  come  to  social  agencies  until  the 
time  of  illness  and  five  families  not  until  some  time  after,  sug- 
gests that  in  these  families  a  fair  degree  of  normality  may  be 
expected,  and  the  chief  element,  and  therefore  the  chief  respon- 
sibility, is  probably  the  health  problem.  Other  things  being  equal, 
a  reconstruction  of  their  health  will  set  them  on  their  feet,  pro- 
viding the  previous  state  of  normality  has  not  been  impaired 
during  the  strain  of  illness. 

The  largest  number,  19  families,  or  55%,  belong  to  the 
group  which  has  been  socially  dependent  prior  to  having  tuber- 
culosis or  prior  to  the  discovery  of  it.  In  these  families  the  social 
factors  must  be  closely  considered  in  any  program  of  care  for  the 
existing  tuberculous  condition. 

In  as  far  as  these  figures  are  suggestive,  they  show  that  the 
clinics'  relief  program  is  of  inconsiderable  size,  and  used  to  sup- 
plement rather  than  take  the  place  of  other  forms  of  organized 
charity. 

32 


Reclassifying  these  35  families  in  an  attempt  to  relate  their 
economic  dependenc}^  to  their  tuberculous  condition,  we  find  that : 

(a)  Prior  to  tuberculous  infection. 

Twenty-one     families     were     apparently     self-sup- 
porting ; 
Eight  families  were  occasionally  dependent ; 
Six  families  were  chronic  dependents. 

(b)  After  tuberculous  infection. 

One  family  still  apparently  self-supporting  (re- 
ceived sanatorium  outfit  only). 

Twenty-seven  families  received  occasional  relief ; 

Seven  families  were  chronic  dependents  (i.  e.,  re- 
ceived som.e  regular  allowance,  which  was  main 
support  of  family). 

MEN'S  WORK 

The  records  of  ^2  wage  earners  were  studied  and  the  infor- 
mation summarized  as  follows  :  ^ 

All  belonged  to  a  low-wage  group ;  that  is,  wages  varied 
from  $6  to  $21  per  week.  One  was  a  telegraph  operator  working 
regularly  and  earning  good  wages,  but  the  amount  was  not  stated. 
Four  whose  wages  were  too  irregular  to  tabulate  were  alcoholic, 
inefficient  or  physically  disabled  (other  than  by  tuberculosis)  to 
such  an  extent  that  they  were  practically  unemployable.  The 
lowest  tabulated  wage,  $6,  was  the  estimated  earnings  of  a  peddler. 
Twenty-four  out  of  32  earned  not  over  $15  weekly;  18  out  of  32 
worked  irregularly. 

Physical  disability  other  than  tuberculosis,  alcoholism,  ineffi- 
ciency and  trade  irregularity  are  factors  in  these  cases.  Any  at- 
tempt to  secure  an  adequate  income  which  will  protect  the  family 
from  the  living  conditions  which  were  favorable  to  the  outbreak 
of  tuberculosis  must  deal  with  these  factors. 

Considering  the  effect  of  tuberculosis  on  the  economic  effi- 
ciency of  these  32  wage  earners,  we  find  that  1 1  were  dead,  as  a 
result  of  tuberculosis,  10  were  living  and  tuberculous.     Of  these 

1  See  Appendix,  pages  72  and  y2>- 

33 


lo,  two  are  working  at  the  same  occupation;  one  a  laborer  at  $13 
a  week,  one  a  flagman  at  $10  a  week.  Three  others  showed  a 
reduced  earning  capacity  since  their  tuberculous  infection.  One, 
who  formerly  earned  $15  as  a  laborer,  now  earns  $10  a  week  as 
a  porter.  Another,  who  earned  $13  as  a  teamster,  now  earns  $12 
as  a  laborer.  The  third,  who  formerly  earned  $15  as  a  painter, 
is  now  working  as  a  janitor  for  his  rent  plus  $15  monthly.  Five 
of  the  10  are  not  working. 

One  factor  in  this  reduced  earning  capacity  may  lie  in  the 
casual  character  of  the  occupation,  but  the  physical  disability 
resulting  from  their  tuberculous  infection  has  undoubtedly  played 
a  large  part  in  reducing  the  wage-earning  capacity  of  this  group. 
The  fact  that  these  men  are  allowed  to  drift  into  any  occupation 
on  their  return  from  an  institution  frequently  accounts  for  their 
subsequent  relapse  and  death.  It  would  seem  the  better  part  of 
economy  to  continue  such  cases  under  observation  and  to  sup- 
plement their  income,  rather  than  to  sever  relations  because  the 
"man  is  back  at  work  and  able  to  support  his  family." 

WOMEN'S    WORK 

An  attempt  was  made  to  summarize  the  available  informa- 
tion regarding  the  work  and  wages  of  the  wives  of  these  32 
wage  earners  as  follows  :  ^ 

Information  available  as  to  their  previous  occupation  was 
too  vague  to  be  used  as  a  basis  for  any  conclusion,  except  as  to 
the  number  of  women  who  were  previously  employed  in  gainful 
occupations.  In  this  low  wage  group  many  women  had  been 
working  even  previous  to  the  death  or  illness  of  the  husband. 
In  six  families  only  the  woman  was  not  helping  with  the  financial 
burden  when  tuberculosis  developed. 

Subsequently  i  woman  died.  Six  wives  still  do  only  house- 
work. The  occupation  of  3  others  was  not  known.  Twenty- 
two  of  these  women  have  taken  up  the  burden  of  support. 

A  large  number  of  women  did  only  home  work  after  the  out- 
break of  disease.  The  women  tend  to  go  into  unskilled  work 
that  takes  part  time,  largely  cleaning  and  laundry  work,  because 

1  See  Appendix,  pages  74  and  75. 

34 


they  have  children  to  care  for.  In  14  cases  part  time  work  only 
was  being  done. 

When  the  wage  earner  is  afflicted,  women  are  driven  into 
industry,  either  to  supplement  the  reduced  earnings  of  the  hus- 
band or  to  undertake  the  entire  support  of  the  family.  Wages 
and  hours  are  entirely  irregular,  but  in  no  instance  are  the  earn- 
ings sufficient  to  maintain  a  decent  standard  of  living  unless 
supplemented  by  children's  earnings  and  relief. 

In  II  families  where  the  man  is  dead,  2  families  have  chil- 
dren over  working  age ;  otherwise  the  woman  has  to  carry  the 
full  burden  of  support  unless  supplemented  by  some  form  of 
relief.  The  weekly  wage  earning  capacity  of  these  11  women 
is  as  follows : 

One  woman   earns $9.00 

Three  women  earn 6.00 

One  woman   earns 5.00 

One  woman   earns 3.50 

One  woman  earns 2.50 

Two  not  known 
Two  dead 

In  the  10  families  where  the  man  is  living  but  tuberculous,  2 
women  are  not  working;  in  one  instance  because  the  man  still 
holds  his  job,  in  the  other  because  grown  children  are  working. 
Four  women  are  the  only  wage  earners  for  their  families. 
Their  occupation  and  earning  capacity  per  week  are  as  follows: 

One    factory  worker $5.00 

One  janitress  and  cleaning,  rent  plus 4.50 

(Woman  not  only   supporting  children  but 
sick  husband  as  well.) 

One  laundress   4.50 

One  factory  worker  4.25 

In  the  group  in  which  the  man  is  living  and  either  not 
tuberculous  or  not  examined,  therefore  supposedly  working  and 

35 


supporting  family — 4  women  are  at  home  and  4  are  supplement- 
ing the  family  income. 

CHILDREN'S   WORK 

Out  of  32  families  only  8  famiHes  have  children  of  working 
age,  14  years  or  over,  13  of  whom  are  or  have  been  working, 
4  among  families  where  wage  earner  is  not  affected  by  disease. 

The  kind  of  work  done  by  these  13  working  children  and 
their  weekly  wage  was  as  follows : 

One  ofhce   boy    $6.00 

One  candy  packer 6.00 

One  elevator  boy 5-00 

One  errand  boy 4.50 

One   factory   hand    : 4.50 

One  electrician's  helper    4.00 

One  laundry   worker    4.00 

One  farm  hand  (tuberculous  boy  supporting  only 

himself) 

One,  employment  unknown    

Three,  odd  jobs    

One  not  working  at  present 

In  addition,  in  i  family  2  children  under  age  were  working 
at  selling  newspapers.  They  had  repeatedly  been  caught  beg- 
ging. Including  these  2  children,  the  employment  of  8  children 
appeared  entirely  unsatisfactory.  Of  the  remaining  7  not  enough 
is  known  to  judge;  but  only  i  (an  electrician's  helper)  was 
learning  a  skilled  trade.  One  candy  packer  and  i  office  boy 
were  brother  and  sister  whose  parents  had  died  of  tuberculosis. 
The  record  shows  that  neither  can  hold  any  job  very  long,  the 
girl  being  indifferent  and  apathetic  and  the  boy  rather  wild. 

HOUSING   CONDITIONS 

Little  definite  information  is  available  regarding  the  housing 
conditions  of  these  famiUes.     It  was  known  that  8  of  the  homes 

36 


of  the  35  families  were  dirty  and  ill-kept.  In  6  families  the 
ratio  of  individuals  to  a  room  was  over  1.5.  Six  families  had 
a  record  of  frequent  moving.     Thus : 

One  family  moved  five  times  in  seven  years. 

One  family  moved  fifteen  times  in  ten  years,  seven  months. 

One  family  moved  seven  times  in  three  years. 

One  family  moved  seven  times  in  four  years. 

One  family  moved  fourteen  times  in  nine  years. 

One  family  moved  ten  times  in  three  years. 

CONCLUSIONS     AS     TO     PHYSICAL     AND     SOCIAL 
STATUS    OF    FAMILIES    STUDIED 

Of  the  217  individuals  included  in  the  35  families  studied, 
20  (9.2%)  were  dead  as  a  result  of  tuberculosis,  34  (15.6%) 
were  living  and  tuberculous.  In  addition  to  this  physical  handi- 
cap, the  data  obtainable  show  that  complicating  personal  and 
individual  factors  are  keeping  these  families  below  standard. 
The  following  tabulation  is  an  attempt  to  summarize  both  the 
physical  and  social  disabilities  from  which  these  individuals  were 
suffering : 

34  Men: 

Physically  below  par  (other  than  tuberculosis)  ....  20 

Industrially  below  par 18 

Cruel  and  abusive 4 

Indifferent 7 

Alcoholic    9 

Deserter  2 

37  Women: 

Physically  below  par  (other  than  tuberculosis — may 

include    childbirth)     22 

Inefficient  (in  the  home) 8 

Indifferent    5 

Alcoholic    4 

Immoral 4 

Mentally    defective i 

37 


146  Children : 

Physically  below  par  (other  than  tuberculosis) 19 

School    irregular , 2 

Below  grade i 

Mentally  defective i 

Unruly   4 

Child   labor 2 

Begging 2 

Inadequate  home  care ' 2 

This  is  all  that  can  be  said  as  the  information  is  so  meagre. 
Absence  of  comment  may  mean  that  conditions  were  good  or  it 
may  mean  that  the  social  worker  failed  to  recognize  the  presence 
of  bad  conditions.  The  outstanding  defects  seem  almost  like 
mountain  peaks  that  succeed  in  obtruding  themselves  above  the 
surface  of  the  prevailing  low  standard.  The  industrial  difficul- 
ties are  most  quickly  noted.  The  housekeeping  disabilities  seem 
next  in  importance.  Further  investigation  would,  without  doubt, 
show  a  maze  of  disabilities  all  reacting  on  each  other.  The 
records  as  a  whole  are  amazing  in  their  haphazard  appreciation 
of  these  people's  difficulties. 

Of  the  35  families  studied  many  have  young  children.  In 
8  families  there  are  children  over  school  age.  The  children's 
needs  seem  to  have  been  disregarded  altogether  unless  we  may 
assume  that,  except  in  the  few  cases  noted,  these  children  were 
attending  school  regularly,  were  up  to  grade  and  were  well  cared 
for  at  home.  Of  the  15  children  who  are  working,  2  are  under 
age,  8  are  working  under  conditions  entirely  unsatisfactory.  Of 
the  remaining  7  not  enough  is  known  to  judge  as  to  their  work 
condition,  but  i  only,  an  electrician's  helper,  is  learning  a  skilled 
trade.  The  general  physical  level  is  low,  but  how  many  are 
actually  in  robust  health  and  how  many  have  physical  disabilities 
not  related  to  their  tuberculous  condition  is  not  known. 

It  is  noteworthy  that  relatives  figured  so  little  in  the  lives  of 
these  families,  at  least,  that  is  the  impression  one  gets  from  the 
social  records.  Financially  we  would  expect  them  to  do  very 
little,  as  the  probabilities  are  that  they  themselves  are  near  the 

38 


margin  of  dependence.  In  8  cases  relatives  gave  some  material 
assistance.     It  was  very  little. 

Other  natural  resources  of  helpfulness  were  not  very  suc- 
cessfully tapped.  The  church  gave  financial  help  in  five  in- 
stances. In  one  instance  this  wa.s  estimated  as  at  least  $ioo. 
Employers  in  no  case  gave  relief  and,  again  judging  from  the 
records,  it  does  not  appear  that  they  were  ever  approached  on 
this  subject.  Adequate  pensions  were  given  in  three  cases  with 
educational  supervision,  otherwise  relief  was  meagre,  intermit- 
tent and  inadequate  during  the  period  of  the  wage  earner's  ill- 
ness, thus  letting  the  burden  fall  too  heavily  on  the  wife.  In 
17  instances  the  woman  subsequently  developed  tuberculosis  or 
was  otherwise  physically  disabled.  As  the  institutional  care  was 
short  and  intermittent,  the  greater  strain  on  the  family  came 
during  illness  which  often  lasted  for  several  years.  All  of  the 
families  belong  to  the  low  wage  earning  group  and  therefore  had 
little  or  no  chance  to  save  for  time  of  sickness. 

The  industries  of  the  men  were  largely  unskilled.  In  18 
cases  the  work  history  was  irregular.  In  5  cases  this  was  due 
to  the  irregularity  of  trade  itself,  in  the  other  13  cases  to  com- 
plicating factors  of  physical  incapacity,  alcoholism,  inefficiency 
and  indifference. 

Previous  to  the  history  of  tuberculosis  infection  a  large  pro- 
portion of  women  have  done  housework  only,  subsequently  6 
only  are  recorded  as  doing  housework,  from  which  it  appears 
that  not  only  the  death  of  the  wage  earner  but  illness  throws  the 
burden  of  support  on  the  woman  and  drives  her  into  industry. 
Hours  and  wages  for  women's  work  are  most  irregular.  Four- 
teen of  the  20  women  working  were  doing  part-time  work. 
Every  tendency  is  to  go  into  unskilled  work,  largely  cleaning  and 
laundry  work. 

The  most  evident  thing  is  that  very  little  was  known  of  the 
background  of  these  families  and  tentatively  one  would  conclude 
that  relatives  play  a  very  small  part  in  their  lives ;  that  the 
church  connection  has  been  largely  lost  as  far  as  any  vital  con- 
nection is   concerned;  that   with  employers  the  relationship   is 

39 


temporary,  shifting  and  in  no  case  does  it  mean  more  than  a 
work  relationship  so  far  as  the  social  records  can  show.  The 
neighborhood  background  can  only  be  concluded  by  one's  knowl- 
edge of  the  West  Side.  The  records  never,  except  by  the  most 
meagre  comments,  take  the  neighborhood  life  into  consideration. 
To  sum  up,  as  far  as  the  testimony  of  the  records  go,  the 
majority  of  the  families  studied  were  deficient  in  the  elements 
essential  to  social  welfare  in  health,  industrial  efficiency,  recre- 
ation, education  and  spiritual  vigor.  In  so  far  as  this  same  tes- 
timony goes,  the  tuberculous  condition  seemed  deeply  imbedded 
in  these  social  disabilities  and  could  hardly  have  been  treated 
separately.  The  records  fail  to  give  a  clear-cut  idea  of  the 
strong  and  weak  points  in  each  family  or  any  measure  of  the 
permanent  progress  made  in  treating  these  families.  Judging 
from  the  repeated  re-openings  of  the  cases,  the  harmful  forces 
are  too  deep-rooted  and  persistent  to  be  removed  by  the  social 
treatment  given. 

METHODS    OF   TREATMENT 

We  come  now  to  a  consideration  of  a  third  object  for  which 
the  present  study  was  undertaken,  namely,  to  point  out  the  "de- 
ficiencies in  both  the  medical  and  social  treatment  of  dependent 
families  with  tuberculosis." 

That  the  problem  of  the  tuberculous  patient  is  not  met  by 
treating  him  alone,  but  must  take  in  his  whole  family  in  its  oper- 
ation, seems  an  established  principle  in  the  care  of  tuberculosis. 
That  inadequate  incomes,  accompanied  by  underfeeding,  bad 
housing  and  worry,  are  obstacles  in  the  way  of  the  physician 
which  must  be  considered  in  any  program  of  care,  is  also  show- 
ing itself  in  the  prevalent  practice  of  clinics  in  supplementing 
the  incomes  of  their  neediest  patients,  either  through  their  own 
organizations  or  by  referring  them  to  some  "relief  society."  But 
whether  medical  care  plus  relief  can  satisfactorily  meet  the 
problem  of  these  families,  or  whether  effective  care  must  in- 
clude "social  treatment,"  has  not  yet  been  clearly  proven. 

Tentatively  we  may  define  social  treatment  as  "action  under- 

40 


taken  to  secure  for  a  family  the  ability  to  insure  its  own  general 
well-being,"  or,  more  specifically,  the  endeavor  to  secure  for  a 
family  resources  in  health,  employment,  education,  recreation 
and  spiritual  vigor. 

Are  there  families  under  clinic  care  who  are  deficient  in  this 
ability  to  "secure  their  own  general  well-being,"  and  if  so,  can 
their  tuberculous  condition  be  treated  separately?  Or  is  their 
tuberculosis  simply  one  manifestation,  one  symptom  of  general 
below-par-ness  which  may  break  out  in  any  of  a  score  of  differ- 
ent ways,  and  which  will  always  be  liable  to  break  out  again  until 
the  deep-rooted  causes  can  be  diagnosed  and  treated? 

If  we  find  conditions  generally  accepted  as  lowering  resist- 
ance to  tuberculous  infection  operative  in  a  majority  of  tubercu- 
lous families,  upon  further  analysis  do  we  not  find  the  cause 
of  these  conditions  imbedded  in  the  social  forces  of  the  family 
and  the  community?  Can  we  not  demonstrate  that,  as  long  as 
we  allow  these  primary  causes  to  go  untreated,  the  same  symp- 
toms are  apt  to  manifest  themselves  and  that  any  treatment  of 
one  symptom  only  is  temporary  and  uneconomic?  If  this  is 
true,  how  can  the  treatment  of  the  social  needs  of  the  tuberculous 
best  be  correlated  with  the  work  of  the  physician  and  nurse? 
Is  there  as  yet  a  technique  of  social  treatment  to  deal  with  these 
"primary  causes?"  Is  this  technique  effective  in  all  cases?  If 
not,  where  does  it  fail  and  why? 

Again,  what  can  be  expected  under  present  conditions  from 
the  clinics?  Certainly  social  workers  should  know  their  point 
of  view,  know  the  handicaps  under  which  they  work,  where 
there  are  gaps  in  their  routine,  where  an  extra  effort  in  the 
same  direction  will  help  their  work,  and  how  much  can  rightfully 
be  expected  from  them  for  the  families  in  which  social  workers 
are  equally  interested.  If  these  points  can  be  fixed  fairly  in 
mind  and  the  method  of  social  work  is  flexible  enough  to  adapt 
itself  to  these  conditions,  social  workers  should  be  more  ready 
to  work  harmoniously  at  the  joint  medical  and  social  problems 
of  tuberculosis  or  to  face  squarely  certain  issues  which  have 
seemed  to  be  irreconcilable. 

41 


MEDICAL   TREATMENT 

Before  proceeding  to  a  detailed  consideration  of  the  methods 
of  treatment  in  vogue  in  the  tuberculosis  clinics  and  the  relation 
of  these  methods  to  the  scheme  of  social  treatment  as  carried 
out  by  the  social  agencies  which  are  also  in  touch  with  these 
families,  it  may  be  well  to  see  what  effect  institutional  care  and 
treatment  have  had  upon  the  tuberculous  condition  of  these  fam- 
ilies. 

Thirty-five  cases,  in  each  instance  the  first  member  of  the 
family  who  had  applied  to  the  clinic  for  care,  were  studied  for 
the  history  of  their  institutional  care,  which  is  shown  in  the 
following  tabulation: 

Length  of  Care  No.  of  Cases 

Under   one   month 6 

One  to  three  months 7 

Three  to  six  months 4 

Six  months  to  one  year 6 

Over  one  year 3 

No  institutional  care 9 

Total    35 

In  8  of  these  cases  the  care  recorded  was  intermittent, 
that  is,  included  two  or  more  admissions  to  institutions.  Of 
these  35  cases,  13  died,  6  are  progressive,  11  improved,  5  ap- 
parently cured.  Day  camp  care  was  noted  in  3  cases,  but  in- 
formation was  lacking  as  to  the  length  of  their  attendance  or  its 
regularity. 

Fourteen  subsequent  cases  in  these  families  also  received 
institutional  care  as  follows: 

Length  of  Care  No.  of  Cases 

Under  one  month i 

One  to  three  months 2 

Three  to  six  months 3 

Six  months  to  one  year i 

No  institutional  care 7 

Total    14 

42 


Thus  in  35  families,  out  of  a  total  of  49  cases  of  tuberculosis 
with  whom  the  clinic  had  been  working,  16  (32.6%)  received 
no  institutional  care. 

It  was  not  possible  to  arrive  at  any  definite  conclusion  as 
to  the  results  obtained  by  the  institutional  care  received  for  the 
following  reasons : 

1.  The  number  of  cases  in  each  group  was  so  small. 

2.  Definite  information  as  to  the  condition  of  the  patient 

on  admission  is  lacking. 

3.  Insufficient  data  as  to  whether  care  had  been  inter- 

mitten  or  consecutive,  i.  e.,  whether  the  patient's 
stay  in  an  institution  had  been  for  a  consecutive 
number  of  weeks  or  months,  or  whether  he  had 
been  admitted  and  discharged  several  times. 

While  this  intermittent  care  may  be  due  to  lack  of  enforce- 
ment of  the  powers  of  forcible  detention,  it  is  probably  true  that 
in  many  instances  a  continuous  stay  in  the  institution  could  be 
secured  voluntarily : 

1.  If  the  patient  were  convinced  that  his   family  was 

being  properly  cared  for. 

2.  If    institutional    life    were    made    more    attractive 

by  eliminating  just  grounds  for  the  repeated 
complaints  regarding  overcrowdng,  failure  to 
classify  patients  according  to  their  social  char- 
acteristics, unattractive  dietaries,  etc. 

Likewise  we  are  unable  to  arrive  at  any  conclusion  as  to  the 
effect  of  institutional  care  of  the  first  case  on  the  subsequent 
infection  of  other  members  of  the  family  for  the  following  rea- 
sons: 

1.  The  length  of  infection  previous  to  admission  to  the 

clinic  could  not  be  shown. 

2.  It  was  not  possible  to  know  definitely  whether  the 

case  first  registered  with  the  clinic  was  the  first 
infection  in  the  family. 

43 


From  the  information  available  for  the  33  cases  who  did 
enter  institutions,  it  seems  that  institutional  care  played  only  a 
small  part  in  the  program  of  care  worked  out  for  these  families. 
In  man}^  cases  it  was  too  short  to  have  any  effect  except  pos- 
sibly in  giving  the  patients  some  training  in  hygienic  methods 
of  living. 

The  fact  that  institutional  care  plays  such  a  small  part  in  the 
history  of  these  tuberculous  people  should  be  realized  and  a  more 
adequate  technique  of  home  care  should  be  developed. 

As  regards  clinic  care,  the  regular  routine  provides  for 
periodic  re-examination,  for  home  visits  by  the  clinic  nurses  and 
for  day  camp  care  in  a  small  number  of  cases.  There  is  no 
record  of  the  adequacy  of  any  of  these  measures  or  of  the 
methods  employed  to  bring  into  line  ignorant  or  indifferent 
patients.  In  other  words,  the  ground  is  covered  extensively 
by  the  clinics,  but  there  appears  to  be  need  for  far  more  intensive 
individual  case  work  if  results  are  to  be  obtained  in  the  home 
care  of  these  cases. 

CO-OPERATION  BETWEEN  MEDICAL  AND  SOCIAL 

AGENCIES  AS  AFFECTED  BY  WORK 

METHODS   OF   EACH 

Before  proceeding  to  a  detailed  criticism  of  the  methods  of 
work  of  the  two  groups  of  agencies  it  should  be  noted  that  these 
criticisms  have  been  gleaned  from  personal  interviews  with  indi- 
vidual workers,  from  attendance  at  conferences  and  from  the 
reading  of  reports,  rather  than  from  any  analysis  of  case  records, 
where  disagreements  are  seldom  recorded,  although  the  basis  for 
the  criticism  of  relief  agency  methods  are  illustrated  in  the 
records. 

The  criticisms  made  by  the  social  agencies  of  the  clinics' 
methods  of  work  can  be  summarized  briefly  as  follows : 

I.  That  the  tuberculosis  specialist  sees  only  the  medical 
problem,  ignoring  the  effect  of  his  plan  of  treat- 
ment on  other  phases  of  the  patient's  develop- 
ment ;  that  the  giving  of  relief  is  on  a  sentimen- 

44 


tal  basis  not  determined  by  any  broad  social 
policy;  that  relief  is  given  without  regard  as  to 
whether  the  right  use  of  it  is  made,  e.  g.,  if  the 
patient  actually  consumes  the  special  diet  pro- 
vided ;  that  the  tuberculosis  nurse's  policy  of 
"handouts"  spoils  the  later  relationship  of  the 
family  and  the  visitor  for  the  social  agency ;  that 
the  clinic  often  gives  relief  w^hen  the  giving  of 
it  makes  the  continuation  of  a  socially  dangerous 
situation  possible. 

2.  That  there  is  inexcusable  delay  in  getting  patients  to 

hospitals  and  sanatoria. 

3.  That  forcible  removal  is  not  often  enough  enforced. 

4.  That  home  supervision  is  inadequate. 

5.  That  disputed  diagnoses  often  keep  the  patient  on  ten- 

terhooks and  finally  discourage  his  attendance  at 
the  clinic. 

6.  That  the  physical  examination  is  too  short  and  super- 

ficial to  be  reliable,  especially  for  the  detection  of 
other  dangerous  symptoms. 

7.  That  the  clinic  does  not  make  sufficient  effort  to  fol- 

low up  patients  who  do  not  attend  regularly,  or 
lapse  altogether,  or  to  secure  examination  of  the 
entire  family. 

8.  That   having  diagnosed   the   need   of   other   medical 

treatment,  e.  g.,  removal  of  tonsils  and  adenoids, 
there  is  no  assurance  that  this  is  carried  out. 

9.  That   clinic   records   are   not   full   enough,   accurate 

enough,  up-to-date  enough,  available  enough. 

The  first  of  these  criticisms  of  the  clinics'  work  relates  to 
action  on  the  part  of  the  clinic  which  involves  a  broader  question 
than  the  medical  aspect  of  the  cases  under  consideration.  Relief 
as  a  therapeutic  measure  may  be  within  the  scope  of  medicine, 
but  relief  as  it  contributes  to  the  family's  activity  as  a  self- 
dependent,  economic  and  social  entity  may  need  other  than  medi- 
cal consideration.     Policies  of  relief-giving  as  well  as  those  in- 

45 


volving  the  maintenance  or  breaking  up  of  a  family  group  must 
be  settled  by  fundamental  considerations  of  the  greatest  total  good 
to  the  family  and  community,  which  both  nurse  and  social  worker 
are  seeking.  We  have  come  to  realize  that  this  cannot  be  done 
without  some  technical  knowledge  of  social  problems^  which  very 
few  nurses  have  as  yet  acquired.  If  the  problem  is  to  be  solved 
by  the  division  of  the  field  between  the  social  worker  and  the 
nurse,  then  the  nurse  must  realize  the  validity  of  the  social 
worker's  principles  in  regard  to  the  social  problem  of  a  tuber- 
culous family.  More  and  more,  however,  nurses  are  adding  the 
training  in  these  principles  to  their  equipment,  and  they  will  be 
increasingly  ready  to  handle  the  whole  problem,  weighing  the 
medical  and  social  needs  of  a  patient  so  as  to  reach  the  best  ad- 
justment, or  better  still,  the  harmonious  solution  of  his  problem. 
In  the  meantime,  social  worker  and  nurse  should  get  together  for 
a  reasonable  conference  on  each  case  as  it  comes  up,  reminding 
themselves  often  of  their  common  aim  in  securing  the  welfare  of 
the  individual,  and  defining  what  this  welfare  consists  of.  It  is 
worth  while  remembering  that  there  may  also  be  an  advantage 
in  the  intensity  with  which  each  specialized  agency  regards  the 
special  need  it  is  meeting. 

When  social  workers  wish  to  suggest  modification  in  the 
medical  treatment  given  to  a  man  because  they  believe  that  not 
merely  his  sickness  but  also  his  status  as  father,  wage  earner 
and  citizen  needs  consideration,  they  have  all  the  disadvantages  of 
the  youngest  member  of  the  fam.ily  of  professions — in  measuring 
up  their  tentative,  pragmatic  and  still  largely  unformed  technique 
against  the  older  one  of  medicine.  If  they  would  only  remem- 
ber to  keep  it  tentative  and  pragmatic !  Do  we  know  yet,  for 
instance,  on  scientific — not  dogmatic — grounds  what  is  a  "socially 
dangerous  situation"?  Every  step  which  can  be  taken  toward 
increasing  the  firmness  and  soundness  of  social  treatment  will 
win  social  workers  a  better  hearing  with  the  medical  specialists. 

The  second  point,  about  inexcusable  delay,  also  needs  further 
analysis.  Is  it  not  sometimes  due  to  the  clinic  being  more  con- 
scious than  social  workers  of  the  inadequate  facilities,  the  other 

46 


more  urgent  cases  pressing  for  attention,  of  the  unattractiveness 
of  institutions  which  makes  them  so  unendurable  to  the  patients 
who  are  sent?  We  need  to  differentiate  pretty  fairly  between 
lack  of  community  resources  and  the  apparent  indifference  of  the 
cHnic  in  order  to  put  pressure  in  the  right  place.  Forcible  re- 
moval is  another  point  at  which  the  health  authorities  have  had 
to  be  wary — to  go  no  further  than  public  opinion  would  sustain 
them  in  the  exercise  of  so  drastic  a  measure. 

The  objections  about  inadequate  home  supervision,  hasty 
medical  examinations  and  failure  in  follow-up  work  have  a  fa- 
miliar ring  to  social  workers.  They  raise  the  question  as  to 
whether  an  attempt  to  cover  fully  the  field  in  some  shape  is  as 
valuable  as  to  establish  standards  in  a  limited  field  which  can  be 
used  as  a  basis  of  education  and  extension. 

The  better  correlation  of  the  work  of  the  tuberculosis  clinics 
with  other  medical  clinics  is  especially  important,  in  order  to  insure 
specialized  treatment  when  morbid  conditions  other  than  tuber- 
culosis are  present.  It  is  equally  necessary,  in  order  to  secure 
treatment  for  physical  defects  contributory  to  tuberculous  infec- 
tion, when  the  special  tuberculosis  clinic  is  not  equipped  to  give 
such  treatment.  In  immigrant  families,  in  indifferent  but  socially 
dangerous  cases,  with  children,  we  cannot  afford  to  leave  this 
correlation  to  the  initiative  of  the  patient. 

The  question  of  disputed  diagnoses  seems  to  lie  so  wholly  in 
the  medical  field  that  we  cannot  do  more  than  mention  it  and  to 
recall  to  the  physicians  as  tactfully  as  may  be  the  hardship  it 
entails  on  a  family.  When  all  is  said,  an  unsound  snap  judgment 
may  bring  greater  and  more  unnecessary  hardship. 

As  to  the  clinic  records,  they  have  been  in  the  past  scrappy, 
inaccurate,  often  out  of  date  and  badly  organized.  Nurses  know 
it,  and  sadly  confess  that  the  most  valuable  information  is  in  the 
heads  of  the  physicians.  While  the  clinic  record  shows  the  date 
of  the  patient's  visit  to  clinic,  there  is  no  way  of  knowing  whether 
this  attendance  met  the  mxcdical  requirement  of  individual  cases, 
as  the  recommendation  of  the  physician  in  this  matter  is  not  re- 
corded.    While  other  physical  defects  are  noted,  there  is  seldom 

47 


information  available  as  to  whether  treatment  for  these  defects 
has  been  secured.  Seldom  do  they  note  the  reason  for  a  patient's 
discharge  from  an  institution  or  reason  for  his  not  going  when 
institutional  treatment  seems  to  be  indicated.  Occasionally  the 
medical  record  indicates  if  the  family  is  hard  to  deal  with,  other- 
wise no  comment  is  made  as  to  the  success  of  home  supervision. 
No  distinction  is  noted  on  the  medical  record  between  lodgers 
and  boarders  who  share  food.  In  recent  years  there  has  undoubt- 
edly been  a  considerable  improvement  in  both  the  medical  and 
social  records  kept  at  tuberculosis  clinics. 

Judging  from  the  cases  studied,  the  clinics  can  be  trusted 
to  cover  the  field  extensively — to  get  in  all  the  members  of  the 
patient's  family,  if  moral  suasion  will  bring  them;  to  do  good 
preventive  work  with  children ;  to  visit  the  home  periodically,  but 
not  enough ;  to  secure  attendance  at  the  clinic,  which  does  not 
necessitate  very  persistent  follow-up  work;  finally,  to  supply 
relief,  indiscriminately  or  not,  as  the  case  may  be,  until  the  relief 
agencies  do  the  job  so  well  that  they  must  recognize  their  motives 
and  methods  as  the  best  available. 

The  indictments  of  the  relief  agencies  by  the  clinics  may  be 
summarized  as  follows : 

1.  That  adequate  relief  in  nourishment,  good  housing, 

freedom  from  worry  are  indispensable  therapeu- 
tic measures,  and  that  the  relief  agencies  give 
meagrely,  defer  the  giving  too  long,  refuse  in 
cases  where  it  should  be  given,  and  give  irregu- 
larly; that  the  tuberculosis  nurse,  owing  to  her 
medical  relationship,  has  the  family's  confidence 
more  completely,  and  is  therefore  a  better  judge 
as  to  when  and  how  much  relief  is  needed. 

2.  That  organized  charity,  having  learned  the  one  fact 

that  institutional  care  is  desirable  for  tuberculous 
people,  tries  to  force  this  method  of  treatment 
through  in  every  case ;  and  where  institutional 
care  is  not  possible  it  is  apt  to  drop  further  action, 
whereas  in  some  cases  home  care  is  not  a  great 

48 


menace,  and  the  existing  menace  is  increased  by 
withholding  adequate  nourishment — that  it  is  nec- 
essary to  consider  individual  prejudices  and  to 
temporize  often. 

3.  That  organized  charity  investigation  antagonizes  the 

patient  and  leads  to  nothing  in  the  way  of  con- 
structive treatment. 

4.  That  organized  charity  has  no  hold  on  the  family  but 

relief. 

5.  That  organized  charity  does  not  succeed  in  rehabili- 

tating the  majority  of  its  families,  and  therefore 
its  efforts  are  more  or  less  futile. 

Considering  in  detail  the  criticisms  made  by  the  clinic  nurses 
of  the  work  of  the  social  agencies  for  the  families  in  whom  they 
are  interested,  social  workers  can  afiford  to  be  frankly  severe  with 
themselves. 

It  is  true  that  in  all  but  a  few  of  the  cases  studied  (three 
pension  cases  notably)  relief  was  meagre,  irregular  and  long  in 
coming;  that  an  entirely  inadequate  conception  of  the  necessary 
standards  of  nourishment,  sleeping  arrangements,  rest  and  out- 
door recreation  was  evident.  The  criticism  that  at  present  they 
seem  unfit  to  judge  what  is  needed  in  such  matters  has  some 
foundation. 

The  length  of  time  many  of  these  families  have  been  known 
to  organized  charity  without  ever  having  been  affected  in  the 
slightest  degree  by  their  relationship  is  startling.  That  the  rela- 
tionship between  organized  charity  workers  and  the  family  hangs 
on  the  question  of  relief,  and  that  only,  seems  also  true  almost 
invariably,  and  because  there  is  no  other  lever,  withdrawing  relief 
is  used  frequently  by  the  visitor  to  get  the  family  to  take  a  de- 
sired action ;  that  this  fact  must  bias  the  sort  of  information  given 
the  visitor,  and  that  therefore  the  nurse  is  apt  to  have  a  franker 
relationship  is  obvious.  If  there  were  no  question  of  withdraw- 
ing relief  except  in  the  most  extreme  instances,  and  if  there  had 
been  numerous  other  ties  established  between  visitor  and  family, 

49 


these  could  be  used  to  get  a  family  to  follow  advice.  The  effort 
should  be  to  bring  about  a  change  in  the  family's  point  of  view, 
rather  than  to  make  them  go  through  certain  actions  from  fear 
of  losing  relief. 

Organized  charity  workers  need,  above  all,  to  develop  the 
art  of  second  best  plans — when  institutions  are  overcrowded, 
urging  further  admissions  only  aggravates  the  conditions  in  the 
institutions,  which  make  patients  hate  to  go  and  unwilling  to  stay. 
At  present  it  is  necessary  to  select  the  most  urgent,  or  most 
helpable  cases,  in  the  meantime  never  ceasing  to  agitate  for  more 
adequate  accommodations,  but  meanwhile  developing  a  technique 
of  home  care  for  cases  that  can't  get  in,  for  cases  that  are  wait- 
ing, for  cases  that  won't  go,  for  cases  that  can  very  well  profit  by 
home  care.  There  are  instances  in  which  a  father  must  be  allowed 
to  die  at  home,  and  the  best  we  can  do  to  safeguard  the  children 
is  to  feed  them  well,  keep  them  out  of  doors,  even  if  it  takes  a 
daily  visit,  and  so  show  our  vital  interest  that  the  family  will 
believe  in  the  good  faith  of  our  advice. 

These  human  reasons  for  the  failure  of  the  best  plan  are 
much  more  quickly  understood  and  appreciated  apparently  by  the 
nurses  than  by  the  social  workers.  Again,  social  workers  are  con- 
stantly getting  irritated  at  and  condemning  a  patient's  state  of 
mind,  while  a  nurse  realizes  that  frequently  the  mentality  of  a 
tuberculous  patient  is  affected  by  the  toxic  action  of  his  disease. 

The  criticism  about  investigation  applies  to  any  sort  of  case 
work.  If  we  could  only  make  our  services  as  real  to  the  mind 
of  the  public  as  our  investigation,  it  might  be  possible  to  connect 
the  two  in  their  minds,  although  in  the  thirty-five  cases  studied 
the  connection  is  not  clear  in  the  records  and  the  criticism  seems 
justified. 

The  waiting  game,  before  a  definite  plan  is  decided  upon,  is 
one  of  the  social  worker's  habits  which  calls  forth  the  condemna- 
tion of  the  nurse ;  but  in  the  cases  studied  up  to  the  record  of  the 
last  two  or  three  years,  the  whole  game  was  a  waiting  game,  and 
there  were  no  plans.  The  recent  records  do  show  improvement 
on  this  head. 

50 


There  are  additional  criticisms  Avhich  are  suggested  by  a 
study  of  these  cases. 

We  are  not  sufficiently  aware  of  the  strain  on  the  other  mem- 
bers of  the  family.  Our  energies  seem  to  flag  when  the  family 
is  examined,  more  or  less  adequately  relieved,  and  the  patient 
has  applied  for  admission  to  an  institution.  In  a  great  propor- 
tion of  this  group  of  cases  the  patient  was  the  man.  It  should 
be  carefully  considered  how  much  work  the  wife  could  wisely 
do  while  she  is  caring  for  her  husband  and  even  after  he  has  gone. 

According  to  the  social  records,  natural  resources  of  help 
are  lacking  in  many  cases,  and  are  very  meagre  where  they 
do  exist  in  these  city  families.  The  records  show  so  little 
study  of  background  that  it  is  almost  impossible  to  say  finally 
that  these  families  have  not  the  normal  connections  which  the 
case  worker  largely  depends  on  to  make  her  work  successful.  But 
if  further  study  proves  this  true,  does  it  not  indicate  that  we  must 
use  artificial  levers  more  largely  to  jack  these  families  up? 

We  must  keep  in  mind  that  under  present  conditions  no  force 
can  be  exercised  to  keep  the  average  patient  in  an  institution,  and 
repeatedly  our  half-hearted  way  of  caring  for  his  family  has 
brought  a  man  home  to  attempt  to  take  up  the  burden  himself, 
thus  jeopardizing  his  cure.  It  is  sure  failure  to  our  treatment  to 
close  the  case  when  the  cured  or  arrested  patient  returns.  Only 
special  interest  and  advice^  constant  supervision  and  readiness  to 
help  share  the  burden  of  support  can  insure  a  man's  not  relapsing. 
This  policy  was  not  apparent  in  any  case,  and  relapses  and  subse- 
quent deaths  occurred. 

SUMMARY 

When  we  have  made  all  these  adjustments  there  still  remain 
the  knotty  problems  of  : 

1.  The  man  who  is  able  but  refuses  to  support  his  family. 

2.  The  family  which  it  is  eugenically  criminal  to  keep 

together. 

3.  The  hopeless   family   who  are   so  unteachable  that 

effort  and  money  seem  misspent  because  they  do 
not  touch  the  situation. 

51 


4-  The  non-sufficient  family  which  will  have  to  be  helped 
along-  indefinitely  to  maintain  a  decent  standard, 
without    any    prospect    of    its    becoming    self- 
sufficient. 
In  the  records  of  cases  studied,  the  social  treatment  given 
seems  to  have  been  slight,   casual  and  limited  almost  solely  to 
times  of  financial  stress — a  sort  of  "lend  a  hand"  policy  which 
may  tide  a  normal  family  over  an  emergency.     It  shows  little 
evidence  of  the  adequate  handling  of  a  case  having  the  elements 
of  normality,  but  demanding  intensive  work  in  physical  rebuild- 
ing, re-education  of  habit  and  careful  readjustment  of  environ- 
ment.    Unavoidably  it  has  failed  with  the  group  where  the  very 
mainspring  of  life  seems  never  to  have  existed. 

Even  to  define  the  social  problem  of  tuberculosis  treatment 
to  this  extent,  to  dififerentiate  treatment  accordingly,  would  be 
a  step  forward.  Are  we  not  ready  to  distinguish  between  cases 
we  can  help  and  those  which  we  have  no  power  to  help,  and  there- 
fore do  not  dare  to  handle?  Furthermore,  are  social  workers 
prepared  to  say  that  these  latter  cases  should  become  the  respon- 
sibility of  the  community,  which  should  have  larger  powers  of 
legal  compulsion  and  take  over  the  care  of  these  cases  for  its 
own  protection? 

Again,  social  workers  have  assumed  exclusive  skill  in  the 
problem  of  handling  relief,  and  therefore  all  the  odium  and  the 
hazards  of  relief-giving  are  heaped  upon  them.  They  need  to 
define  their  field  of  work  to  themselves  and  to  limit  their  intake 
accordingly.  They  need  to  dare  to  say  when  they  do  not  know 
or  when  they  think  a  problem  hopeless.  They  need  records  that 
will  be  some  index  to  the  normality  and  helpability  for  the  fam- 
ily. If  this  be  done  they  will  have  given  validity  to  their  conten- 
tions in  cases  involving  co-operation  with  other  agencies. 

As  the  best  means  of  securing  a  workable  basis  for  such 
co-operation  might  be  suggested  : 

I.  A  broader  study  of  the  problem  of  family  welfare 
involved  in  a  particular  case,  and  in  the  light  of 
additional  knowledge  to  see  if  the  ultimate  prob- 
lem is  not  the  same  for  both  agencies. 

52 


2.  A  better  definition   of   the   scope   of   each   agency's 

work. 

3.  A  better  understanding  of  the  p^irpose  of  the  detailed 

processes  or  methods  of  work  of  each  agency. 

4.  An  appreciation  of  the  Hmitations  imposed  upon  each 

agency  by  lack  of  community  resources,  legal 
restrictions,  limited  finances. 

5.  A  better  organized  machinery  for  securing  more  fre- 

quent conferences  between  the  two  groups  of 
agencies  on  problems  in  which  both  are  inter- 
ested. 

6.  The    exertion   of    pressure   on   each   organization   to 

cause  it  to  square  its  methods  with  its  professed 
ideals. 

In  snap  judgments  we  are  apt  to  attribute  most  of  the  mis- 
takes we  think  we  see  to  a  failure  in  this  last  named  particular, 
whereas  they  may  be  due  to  either  more  excusable  or  improvable 
causes.  If  this  is  true,  we  may  be  ready  to  face  more  easily 
those  issues  in  which  our  differences  seem  to  be  irreconcilable. 
Perhaps  we  may  be  able  to  face  facts  still  harder  to  admit, 
namely,  that  there  are  people  whom,  with  our  present  equip- 
ment of  skill  and  technical  knowledge,  we  are  not  able  to  help, 
people  who  so  far  as  we  are  concerned  are  unimprovable. 


53 


Conclusions  and  Recommendations 

Returning  to  a  consideration  of  the  objects  for  which  the 
present  study  was  undertaken  as  stated  in  Part  I  of  this  report, 
there  still  remains  to  be  considered  the  fourth  object,  namely, 
"to  suggest  possibilities  for  the  employment  of  special  tubercu- 
losis funds  which  will  bring  in  the  largest  ultimate  returns." 

Let  us  recapitulate  the  findings  of  the  comparative  study  of 
the  relief  and  non-relief  families,  which  were  as  follows : 

1.  That  the  relief  families  show: 

a.  Poorer  housing  conditions. 

b.  A  longer  tuberculous  history. 

c.  A  greater  incidence  of  infection. 

d.  A  larger  proportion  of  wage  earners  with  tubercu- 

losis, both  living  and  dead. 

e.  A    larger    proportion    of    women    working    and 

tuberculous. 

f.  A  larger  number  of  children  under  i6  with  a  pro- 

portionately   greater    number    infected    with 
tuberculosis. 

2.  The  two  groups,  both  relief  and  non-relief  families,  be- 

long to  the  same  wage  earning  class  with  few  excep- 
tions. 

3.  The  non-relief  group  shows : 

a.  A  much  larger  number  of  adult  children  infected 

with  tuberculosis,  the  majority  of  whom  are 
or  have  been  working. 

b.  A  larger  income  due  chiefly  to  the  work  of  these 

adult  children. 

4.  Eighty-six   per   cent,    of    the   relief    families   have  been 

known  to  various  relief  agencies  for  periods  extending 
from  6  months  to  21  years,  of  whom  8^%  had  re- 
ceived no  relief,  15^%  had  received  temporary  relief, 
45%  intermittent  relief,  31%  continuous  reHef. 
The  intensive  study  of  35  relief  families,  which  is  given  in 
Part  II  of  the  report,  strongly  indicates  that  our  present  tech- 

54 


nique  for  handling  a  large  proportion  of  these  families  is  not 
adequate  to  secure  results.  In  other  words,  that  we  are  unable 
to  rehabilitate  families  in  which  "the  very  mainspring  of  life 
seems  never  to  have  existed."  In  view  of  the  limited  facilities 
at  our  disposal  we  are  urged  "to  define  our  field  of  work,  differ- 
entiate our  treatment,  and  to  limit  our  intake  accordingly." 

On  the  basis  of  these  findings  we  therefore  offer  the  fol- 
lowing recommendations  for  the  employment  of  special  tubercu- 
losis funds,  particularly  with  reference  to  those  funds  raised 
by  organizations  auxiliary  to  tuberculosis  clinics : 

First:  To  furnish  the  necessary  equipment  for  taking  the 
"cure,"  such  as  sanatorium  outfits ;  provisions  for  sleep- 
ing arrangements  which  may  be  necessary  to  continue 
the  "cure"  at  home. 

Second  :  To  provide  loans  : 

a.  To  discharged  sanatorium  cases,  either  to  relieve 

the  economic  pressure  during  the  necessary 
period  of  convalescence  or  to  permit  the  es- 
tablishment of  these  sanatorium  graduates  in 
business. 

b.  To  supplement  family  incomes  in  order  to  enable 

the  adult  tuberculous  children  who  are  con- 
tributing thereto,  to  cease  work  and  take  the 
"cure." 
Third :  To  provide  increased  facilities  for  preventive  work 
with  children,  such  as : 

a.  Country  homes  for  continuing  care  of  physically 

sub-normal  children  exposed  to  infection. 

b.  Summer  vacation  homes  for  children  of  tubercu- 

lous families. 

c.  Temporary  homes  for  children  under  four  whose 

mothers  may  need  institutional  care. 

d.  Educational     classes,     i.  e.,     corrective     exercise 

classes,  cooking  classes. 

Finally,  if  we  have  the  courage,  whether  we  be  social 
workers  or  medical  workers,  let  us  admit  frankly  our  failures, 

55 


recognizing  that  some  were  unavoidable  considering  the  material 
upon  which  we  have  been  working  and  the  limitations  of  our 
present  technique,  but  that  others  have  been  due  to  our  own 
imperfections,  our  lack  of  tolerance,  of  experience,  of  skill,  of 
knowledge.  And  if  our  admitted  failures  are  still  with  us  in 
the  flesh,  a  broken  family  that  we  have  not  mended,  a  temporary 
dependent  whom  through  mistaken  kindness  we  have  confirmed 
in  his  dependency,  let  us  not  trj^  to  shift  the  burden  elsewhere, 
but  rather  do  our  best  to  meet  the  responsibility  created  by  our 
own  mismanagement  in  the  past. 


56 


APPENDIX 


NATIONALITY  OF  FAMILIES  STUDIED 


Nationality 

Relief 
Families 

Non-Relief 
Families 

United  States 

30 
25 
12 

2 

8 

Italy 

5 

Ireland 

4 

Austrian 

3 

German 

2 

Hungarian 

6 

English 

1 

Roumanian 

2 

Polish 

Bohemian 

5 

French 

1 

Russian 

27 

Total 

74 

64 

59 


HOUSING— APARTMENTS  CLASSIFIED  ACCORDING  TO  NUMBER 
OF  ROOMS  PER  APARTMENT 


No.  OF  Rooms  in  Apartment 

Relief  Families 

Non-Relief  Families 

No. 

Per  Cent. 

No. 

Per  Cent. 

2 

12 
28 
24 
5 
1 
0 
4 

16 

37.5 

33 

7 

1.4 

'5 

2 
15 

27 

11 

6 

2 

1 

3 

3 

24 

4 

43 

5 

17 

6 

9H 
3 

7 

No  infnmna.tinn 

Total 

74 

64 

60 


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62 


HOUSING— GENERAL  CLEANLINESS 


Relief  Families 

Non-Relief  Families 

No. 

Ppr  Cent. 

No. 

Per  Cent. 

Good 

29 

22 

15 

4 

41 
31 
21 

35 
21 

6 

56 

Fair 

33 

Bad 

Not  Stated 

9>^ 

Total 

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62 

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69 


LENGTH  OF  RECORDS  COMPARED  FOR  SOCIAL  AND  MEDICAL 

AGENCIES 


Length  of  Record 


Under  6  months . .  . 
6  months  to  1  year 

1  year  to  2  years. . . 

2  years  to  3  years. . 

3  years  to  4  years. . 

4  years  to  5  years. . 

5  years  to  6  years. . 

6  years  to  7  years. . 

7  years  to  8  years. . 

8  years  and  over. .  . 
No  Social  History. . 

Total 


Relief  Families 


Social  History 


% 


7 

10 
10 
9 
7 
9 
2 
1 
9 
10 

74 


9 
13J^ 
IBM 
12 

9 
12 

2M 
1.3 
12 

13M 

100% 


Tuberculosis 
Clinic  History 


4 

5 
21 
15 

19 
2 
5 


74 


% 

5 

28 
20 

251^ 

W2 

6M 


Non-Relief 
Families 


Tuberculosis 
Clinic  History 


16 
11 

15 
7 
3 
7 
2 
1 
1 
1 


64 


% 

25 
17 
23 
11 

11 

2^ 

IM 
IM 


100% 


70 


AMOUNT  OF  TUBERCULOSIS 

35   FAMILIES    STUDIED    IN   PART   II 


Total 

Tuberculous 

Not 
Tuberculous 

Not 
Exam- 
ined 

Dead 

Dead 

Living 

Dead 

Living 

Cause 

Not 
Known 

Men 

34 

*12 

til 

3 

8 

Women 

37 

3 

12 

tl5 

t  7 

Adult  Children 

15 

2 

6 

7 

Children  under  16 

131 

5 

9 

5 

92 

16 

4 

Total 

217 

20 

9.2% 

34 

15.6% 

5 

116 

38 

17.5% 

4 

*  Includes  first  husband  of  one  woman, 
t  Includes  one  relative  (man's  brother), 
j  Two  relatives  in  fractional  family. 


71 


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73 


THIRTY-TWO  WAGE-EARNERS'  WIVES 
I.    HusBAiirDs'  Earnings  too  Ikregular  to  State 


Case 
No. 


Previous 


Present 


Remarks 


32 

43 

51 
47 
35 


Housewife 

Cleaner $3.50 

Housewife 

Housewife 

Glove  fact $5.00 

Furs 10.00 

Restaurant 5 .  00 

(Womanand  children 
serted.) 


Cleaner,  part  time.  .$5.00 

Janitress,     cleaning     part 

time Rent,  $3.50 

Sewing  part  time 


Chocolate  fact $5 .00 


living  with  man,  father  of 


Ale;  indiff.       2  child, 
sell  newspapers. 

Phys.  disabled — tb. 

Ale.     Dead  of  tb. 


children    having    de- 


II.     Husbands 

'  Earnings  Under  $12.00  per  Week 

Case 
No. 

Previous 

Presen 

r 

Remarks 

63 

Housewife 

Cleaning  and  wash- 
ing. .  .  $6.00 

Housewife 

Housewife 

Phys.  disab. 
Tb. 

36 
41 

Same 

Housewife 

Dept.  H.    MUk 
part  time .... 

...$6.00 

Depot, 

. . .$2.50 

37 

Cigar  fact 

Housewife 

Housewife  (andclean- 
er      after      man's 
death) $4.50 

Liv.  tb. 

55 
56 

Cleaner 

...$5.00 

Phys.  disab. 
Tb. 

62 

Housewife 

Cleaner 

...$9.00 

Phys.  disab. 

III.     Husbands'  Earnings  $12-$15  per  Week 


Case 
No. 

Previous 

Present 

Remarks 

46 

Housewife 

Dead  of  tb. 

53 
39 

31 

Housewife 

Janitress  and  fact.. 
(During  husband's 

Housewife 

Housewife 

Cleaner $6.00 

Factory,  part  time . .  $4 .  25 

illness.) 

Housewife 

Tb. 

57 

Cleaning 

Tb.    (1  son  electrician, 

61 

Housewife   

$4). 
Dead  of  tb. 

52 
50 

Janitress  and  rent 

$1.80 
Housewife 

Laundress $4 .  50 

Artificial  flowers. . .  .$1 .00 

(1  child  fact $4.50) 

Factory $6.00 

Cleaner,  part  time 

1  child  tb. 

54 
33 

Factory $6.00 

Cleaner $5.00 

Phys.  disab. — tb. 
Ale;  indiff. 

74 


IV.     Husbands'  Earnings  $15 


Case 
No. 

Previous 

Present 

Remarks 

38 
34 

CL,  washing..  .$6.00 
(During  man's  illness) 
Housewife 

Folds      envelopes 
time 

Cleaning 

Janitress     and     c 
rent  + 

Dept.    H.    Milk 
part  time 

part 
.$6.00 
.S6.00 
eaning 
.$4.50 
depot, 
.$2.50 

Indiff.;  tb. 

44 
60 

Washing $3.00 

Housewife 

Housewife 

Phys.  disab.;  indiff. 

42 

Housewife 

Phys.  disab.  (1  child 
farmhand;  keep,  $1.00 
per  wk.) 

Phys.  disab.;  ale;  indiff. 

Phys.  disab. 

40 

Housewife 

Crochet 

Washing 

.$2.00 
.$2.50 

45 

Washing  and  janitress. 
Rent    +    $5     (1st 
husband  died  of  tb. 
Driver,    $8,    irreg. ; 
ale;  indiff.) 

V.    Husbands'  Earnings  Over 


Case 
No. 

Previous 

Present 

Remarks 

64 

48 

49 

Housewife 

Housewife 

Housewife 

Housewife 

Washing  (?)  part  time.    3 

grown  sons  work  irreg. 

Housewife 

75 


ESTIMATED    ANNUAL    EXPENDITURES    FOR 
TUBERCULOSIS 

The  City  spends  :  ^ 

For  Institutional  care  of  tvtberculosis  pa- 
tients       $1,715,485.46 

For  Home  Care : 

a.  Clinic  treatment,  visiting  nursing 277,311.09 

b.  Public    School   Fresh-Air   Classes....  100,000.00 
For   Laboratory    14,777.50 

$2,107,574-05 
Private  Institutions  and  Agencies  2  spend  : 

For  Institutional  Care  60,710.90 

For  Home  Care 310,031.10 

$370,742.00 

$2,478,316.05 

The  expenditures  for  Institutional  Care  from  private  sources  include : 

Hospital  and  House  of  Rest  for  Consump- 
tives           $45,401.87 

Bedford    Sanatorium    (Brooklyn    Tuberculosis 

Committee)     8,000.00 

Bellevue  Settlement  House,  annual  cost  (Belle- 

vue    Women's    Auxiliary)     5,623.16 

Summer  Home  for  Children  of  Tuberculous 
Families,  annual  cost  (Presbyterian 
Hospital)     1,685.87 

Total    $60,710.90 

The  expenditures  for  Home  Care  by  private  agencies  include : 
Private     Institutions,     for    clinic     nurses'     and    physicians' 

salaries    $20,000.00 

Philanthropic   Agencies    290,031.10 

United  Hebrew  Charities   $45,404.00-!- 

Hebrew  Sisterhoods   (estimated)    20,642.00-!- 

C.  O.  S.    (estimated)    25,000.00 

A.  I.  C.  P.: 

In  patients'  homes  $15,738.00 

In   Home   Hospital    45,102.78 

Outside  contributions   for  Home 

Hospital    1,629.92 

62,470.70 

Joint  Tuberculosis  Committee   43,433-00 

Auxiliary  Funds,   to   Tuberculosis    Clinics....       44,555.40 


1  1914. 

-  Last  fiscal  year's  figures  available  at  time  report  was  prepared. 

76 


Bellevue   (1915)    $8,827.80 

Relief   $6,567.17 

Salaries    2,161.88 

Sundries    98.75 

Health  Department    (1915)    18,275.56 

(Includes  Day  Nursery,  $6,905.34) 

N.  Y.  Hospital 275.00 

Presbyterian    Hospital    7,848.48 

(Includes  salaries,  $2,700) 

St.  Luke's   7S3-00 

Vanderbilt    8,575.56 

(Includes  salaries,  Day  Camp  and  Clinic) 

Brooklyn  Bureau  of   Charities 30,026.00 

Brooklyn  Jewish   Charities    18,500.00 


Total    $310,031.10 

Excluding  the  amount  spent  by  subsidized  private  institutions  over 
and  above  the  per  capita  payments  made  to  them  by  the  City,  we  can 
summarize  the  annual  cost  of  the  care  of  tuberculosis  to  the  City  of  New 
York,  contrasting  the  amount  spent  on  Institutional  Care  with  the  amount 
spent  on  Home  Care  as  follows : 

Institutional  (chiefly  medical  care)  : 

By  the   City    $1,730,262.96 

By  private  agencies  60,710.90 

$1,790,973.86 

Home  Care  (medical  and  social  and  relief)  : 

By  the  City  $377,3ii.09 

By  private  agencies    310,031.10 

687,342.19 

$2,478,316.05 


77 


THE  TROW  PRES 
NEW  YORK 


DUE  DATE 


Ar' 


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-    Oct'[l^Qo^ 


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Printed 
in  USA 


COLUMBIA  UNIVERSITY  UBRARIES 


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